Document Type : Original Article
Authors
1 MSc, Medical Record, Management, Treatment of Social Security. Isfahan, Iran (Corresponding Author)Email: ab.sh80@yahoo.com
2 Lecturer, Medical Record, Isfahan University of Medical Sciences, Isfahan, Iran
Abstract
Introduction: Quantitative analysis of medical records is effectiveness factors in hospital policies, assessment of treatment team performance, and improve executive activities in hospital and they are the principle tool for medical audit. Despite the importance of evaluation and high cost and time, it was not intentioned enough. This paper review the result of Quantitative analysis of medical records of patients admitted in the Gharazi hospital of Isfahan, Iran. Methods: In this descriptive and cross-sectional study, the medical records of all patients admitted in the hospital from the first April 2008 until the end of March were evaluated. Sampling method was census and 26284 number of cases were studied Data collection tool was the checklist that was extracted from medical record text. Researcher referred to the medical record department and data from hospital records were extracted and compiled the checklist and analyzed by SPSS. Results: The most frequency of failure of patients file were related to Ear, Nose and Throat (ENT) specialists (38%) and Maxillofacial Surgery department professionals had not any defect in their patients file record. Conclusion: Quantitative analysis of medical records Based on the desired topics of documentation showed that the most failure of patient records were related to documentation of date entry by documentary makers (91%) and the lowest deficit was related to data entry (1.1%). Few percent of the cases (1.2%) were not assessed in medical record. Considering the results of this study, the Gharazi hospital of Isfahan, Iran is planning to control the case documentation and medical records evaluation by applying appropriate management tools. Keywords: Information Evaluation; Inpatients; Medical Records; Hospitals.
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