Impact of an educational intervention on medical records documentation

Abstract

BACKGROUND: Inaccurate and incomplete documentation can lead to poor treatment and medicolegal consequences. Studies indicate that teaching programs in this fi eld can improve the documentation of medical records. The study aimed to evaluate the effect of an educational workshop on medical record documentation by emergency medicine residents in the emergency department. METHODS: An interventional study was performed on 30 residents in their fi rst year of training emergency medicine (PGY1), in three tertiary referral hospitals of Tehran University of Medical Sciences. The essential information that should be documented in a medical record was taught in a 3-day-workshop. The medical records completed by these residents before the training workshop were randomly selected and scored (300 records), as was a random selection of the records they completed one (300 records) and six months (300 records) after the workshop. RESULTS: Documentation of the majority of the essential items of information was improved significantly after the workshop. In particular documentation of the patients' date and time of admission, past medical and social history. Documentation of patient identity, requests for consultations by other specialties, fi rst and fi nal diagnoses were 100% complete and accurate up to 6 months of the workshop. CONCLUSION: This study confirms that an educational workshop improves medical record documentation by physicians in training.

Patient self‐report versus medical records for smoking status and alcohol consumption at Aboriginal Community Controlled Health Services

“…There is some evidence that educational and training programs and feedback are effective in improving medical record documentation by healthcare providers. 27 Updating or redesigning record forms can also help to improve documentation. 27,28 Medical records are important for both identifying at-risk patients and for service-level reporting and analysis, and it is therefore important for healthcare services to maintain accurate and up-to-date records.…”

“…27 Updating or redesigning record forms can also help to improve documentation. 27,28 Medical records are important for both identifying at-risk patients and for service-level reporting and analysis, and it is therefore important for healthcare services to maintain accurate and up-to-date records. The failure to document risk status is also a potential barrier to continuity and coordination of care, especially in services with high staff turnover.…”

“…Such mechanisms might include staff training or automated prompts for practitioners to complete or update fields. There is some evidence that educational and training programs and feedback are effective in improving medical record documentation by healthcare providers 27 . Updating or redesigning record forms can also help to improve documentation 27,28 .…”

The Influence of Knowledge and Perceptions of Doctors on the Quality of Medical Records

“…The research carried out on resident doctors reported an increase in the quality of medical record documents after training activities/workshops. [20][21][22] A similar study in an Ethiopian hospital stated that the presence of training interventions significantly increased the completeness of filling in medical records. 23 Dewi and Agustina stated that medical officers' compliance, such as those in charge, is lacking due to their business.…”

Medical record documentation quality in the hospital accreditation

“…It is demonstrated by evidence that educational interventions can significantly improve documentation quality among doctors. [ 25 ] Some interviewees claim performing clinical work and documentation by nurses has reduced the effectiveness of documentation. The need for trained employees in the field of documentation and its impact, on the other hand, should be taken into account.…”