Document Type : Original Article
Authors
Abstract
Introduction: Users of medical record information in accordance to relying on data and health information, they demand quality. Proper storage, maintenance, and archiving of old medical records forms for different purposes has led to lack of enough storage space and retention problems for health services organizations. The objective of this study is to assess the effectiveness of medical record information by different users and the length of storage and retention time at Alzahra academic medical center.Methods: This research is an applied, descriptive cross sectional study. The research population included all medical records (about 6000 medical records) of patients which have been demand by users in the first half of 2008 and selected by Census sampling method. Research findings was collected in the form of checklist by referring directly to the Medical Records Department Center and extract data from documents and user requests information about the patients file. Validity of this instrument was confirmed by experts. Data analyzed by SPSS software and descriptive analysis tests.Results: The most requests for medical records information was made by the patient themselves in 36.4% of cases; followed by law enforcement agencies at 27.8%, insurance companies at 23.1%, and quality assurance committees at 1%. The requests time frame for of medical records information after discharge was one year with 73.3%, and 94% after 3 years of patient discharge. From the point of view of request time frames, the oldest request was made 14, 11, 11, 1, 15 and 13 years after the patient discharge respectively. The most requests for medical record forms from the patient chat were discharge summary, operating room report forms, and echocardiography report forms. From the point of view of disease code, the most requests for medical records was related to injuries and related disabilities and poisoning and overdose cases at 30% and 1% for eye diseases.Conclusion: These study results showed that utilization of medical records information decreases over the time and it is not cost effective to keep about 95% of primary files for more than three years. In addition, 95% of disease information regarding to psychological and behavioral disorders, congenital anomalies and malformation and chromosome aberrations have been requested over seven years after creating the file which can be kept separately, Therefore, the results of the study suggests that health services managers and policy makers should adjust the time frame for storage and retention of medical records in their temporary and permanent archiving methods according to the utilization patterns of their users and customers as far as possible.Key words: Medical Records; Hospitals; Self Efficacy; Users; Information.
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