Documentation of Medical Records in Hospitals of Mazandaran University of Medical Sciences in 2014: a Quantitative Study

Abstract

Introduction: Documentation of patient care in medical record formats is always emphasized. These documents are used as a means to go on treating the patients, staff in their own defense, assessment, care, any legal proceedings and medical science education. Therefore, in this study, each of the data elements available in patients' records are important and filling them indicates the importance put by the documenting teams, so it has been dealt with the documentation the patient records in the hospitals of Mazandaran province. Method: This cross-sectional study aimed to review medical records in 16 hospitals of Mazandaran University of Medical Sciences (MazUMS). In order to collection data, a check list was prepared based on the data elements including four forms of the admission, summary, patients' medical history and progress note. The data recording was defined as "Yes" with the value of 1, lack of recording was defined as "No" with the value of 2, and "Not applied" with the value of 0 for the cases in which the mentioned variable medical records are not applied. Results: The overall evaluation of the documentation was considered as 95-100% equal to "good", 75-94% equal to "average" and below -75% equal to "poor". Using the stratified random sample volume formula, 381 cases were reviewed. The data were analyzed by the SPSS version 19 and descriptive statistics. Results: The results showed that %62 of registration and all the four forms were in the "poor" category. There was no big difference in average registration among the hospitals. Among the educational groups Gynecology and Infectious were equal and had the highest average of documentation of %68. In the data categories, the highest documentation average belonged to the verification, %91. Conclusion: According to the overall assessment in which the rate of documentation was in the category "week", we should make much more efforts to reach better conditions. Even if a data element is recognized meaningless, unnecessary and repetitive by the in charge of documentation, it should not be neglected and skipped. In order to solve the problems of these types, it is suggested to discuss the medical records forms and elements that seem unnecessary in the related committees.

Assessment of Medical Records Documentation in Secondary Health Care Facilities in Kafr El-Sheikh and El-Mahalla El-Kubra Cities

“…Almost all documentation items of patient identification part were present in more than 70% of checked records in El-Obor Health Insurance Hospital. This finding is consistent with the results of another study conducted in Iran, (2016) where it showed that data registration average in patient identification part of the teaching or University Hospitals was 53% and in other hospitals it was 52% [8] . In another study in Iran, (2017) that showed that mean documentation of demographic characteristics of the patient was 49% [9] .…”

“…Recording of clinical progress notes at least once a day was 31% in Kafr El-Sheikh General Hospital, 18.5% in El Obor Health Insurance Hospital and 9% in El-Mahalla El-Kubra General Hospital. On the other hand, in the study of assessment of medical records documentation in Iran, (2016) that showed that the average of data registration in the sheets of disease progress in teaching hospitals was 75% and 86% in non-teaching hospitals [8] .…”

Assessment of the documentation completeness level of the medical records in Basrah General Hospital

“…Especially those related to Gynecology/ Obstetric department. [15] All of the present study records (in Gynecology/Obstetric and surgical words) were found to be poorly documenting the physician's notes related to the patient's state and details of any improvement / deterioration of his/her condition. A close similar result was found by a cross-sectional study done in Iran during 2014 involving reviewing completeness of patient's medical records in 16 hospitals within the geographical area of Mazandaran province.…”

Maternal Death Surveillance and Response in Tanzania: Comprehensiveness of Maternal Deaths Narrative Summaries and Action Points from Death Reviews

“…The proportional score of each summary was ultimately divided into be poor, average, or good/comprehensive if it had 0-74%, 75-94% or more than 94% of the required information respectively. The cut off points were decided based on having been used in a study done by Mohseni et al in Iran (15), and were used for analysis and description purposes and are not recommended as standard cut off levels. Action plans were considered to be SMART if all the criteria were met.…”

“…Oftentimes, health care providers fail to follow guidelines in documenting patients' information by prioritizing care over documentation and so the abstracted information may be inadequate (14). Studies from United States and Iran have shown record keeping in medical les in health facilities are weak and face challenges as health care providers fail to follow recommendation during gathering and storing of information (12,(15)(16)(17). While in Northern Tanzania, a report on MDSR implementation by Maternal and Child Survival program and other partners revealed most facilitiesm edical records were not su cient to decide the cause of death and substandard care (18).…”