نوع مقاله : مقاله پژوهشی
نویسندگان
1 دانشگاه علوم پزشکی زاهدان، زاهدان، ایران.
2 گروه پزشکی اجتماعی، دانشکده پزشکی، دانشگاه علوم پزشکی زاهدان، زاهدان، ایران.
3 گروه فیزیولوژی، دانشکده پزشکی، دانشگاه علوم پزشکی زاهدان، زاهدان، ایران
4 مرکز تحقیقات سلامت بارداری، دانشگاه علوم پزشکی زاهدان، زاهدان، ایران.
چکیده
مقدمه: مستندسازی پرونده‌های پزشکی به شیوه صحیح از امور مهم در طی فرآیند تشخیص و درمان بیماری می‌باشد و به لحاظ درمانی، حقوقی، مالی و پژوهشی مهم است. هدف از انجام این تحقیق، تعیین میزان آگاهی دانشجویان پزشکی از اصول مستندسازی پرونده‌های پزشکی بود.
روش بررسی: این مطالعه از نوع توصیفی-تحلیلی مقطعی بود که در سال تحصیلی ۱۴۰۰-۱۴۰۱ در دانشگاه علوم پزشکی زاهدان اجرا شد. جامعه پژوهش شامل دانشجویان پزشکی در مقاطع کارآموزی، کارورزی و دستیاری بودند. حجم نمونه ۲۶۰ نفر بود که با استفاده از روش نمونه‌گیری سهمیه‌ای انتخاب شدند. ابزار جمع‌آوری داده‌ها پرسشنامه‌ای محقق ساخته بود که روایی و پایایی آن مورد تایید قرار گرفت. برای توصیف میزان آگاهی دانشجویان بر حسب متغیرهای مورد بررسی از آمارهای توصیفی (فراوانی، درصد، میانگین نمره و انحراف معیار) و آزمون‌های تحلیلی (T-test و ANOVA) استفاده شد.
یافته‌ها: میانگین نمره آگاهی کسب شده توسط جامعه پژوهش 02/14±92/64 از نمره کل 74 بود. بیشترین و کمترین میانگین نمره به ترتیب مربوط به اصول مرتبط با چارچوب زمانی تکمیل اطلاعات و اصول کلی مستندسازی پرونده پزشکی بود. آزمون رابطه میان متغیرهای پژوهش نشان داد که فقط رابطه میان دو متغیر میزان آگاهی و دوره تحصیلی دانشجویان معنی‌دار بود.
نتیجه‌گیری : در این مطالعه میزان آگاهی دانشجویان از اصول مستندسازی پرونده پزشکی در حد مطلوب بود. ولی با مقایسه نتایج متفاوت حاصل از این پژوهش با مطالعات مشابه قبلی، می‌توان گفت که آموزش اصول مستندسازی در طول زمان تاثیر مثبتی بر ارتقاء سطح آگاهی دانشجویان داشته است.
کلیدواژه‌ها
موضوعات
عنوان مقاله [English]
Awareness of Medical Students Regarding Principles of Medical Record Documentation
نویسندگان [English]
- Zohre Mobasheri 1
- Javid Dehghan Haghighi 2
- Mohammad Reza Shahraki 3
- Afsaneh Karimi 4
1 Zahedan University of Medical Sciences, Zahedan, Iran
2 Department of Social Medicine, Zahedan University of Medical Sciences, Zahedan, Iran.
3 Department of Physiology, Medical School, Zahedan University of Medical Sciences, Zahedan, Iran.
4 Pregnancy Health Research Center,, Zahedan University of Medical Sciences, Zahedan, Iran.
چکیده [English]
Introduction
Accurate documentation of medical records is one of the important issues during the process of diagnosis and treatment of the disease. It is very important in terms of treatment, legal, educational, financial and research. This study aimed to determine awareness of medical students about principles of medical records documentation.
Methods: This descriptive-analytical and cross-sectional study was conducted in 2022-2023 at Zahedan university of medical sciences. The research population included medical students in the preclinical, clinical, and residency levels. The sample size was 260 medical students and the sampling method was quota sampling. The data collection tool was a researcher-made questionnaire. The validity and reliability of questionnaire were confirmed. Descriptive statistics (frequency, percentage, mean, and standard deviation) and analytical tests (T-test and One-way ANOVA) were used to analysis the research data.
Results: The average awareness score obtained by the research community was 64.92±14.02 out of 74. The highest and lowest average scores were respectively related to the principles about the time frame of completing the information and the general principles of documenting the medical record. The test of the relationship between the variables of the research showed that only the relationship between the two variables of awareness level and educational level of students was significant.
Conclusion: In this study, the level of students' awareness about the principles of documenting medical records was optimal. But by comparing the different results of this research with previous similar studies, it can be said that teaching the principles of documentation over time has had a positive effect on improving the level of students' awareness.
کلیدواژه‌ها [English]
- Documentation
- Medical Records
- Diagnosis
- Procedure
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