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Paper Information

Journal:   AVICENNA JOURNAL OF CLINICAL MEDICINE (SCIENTIFIC JOURNAL OF HAMADAN UNIVERSITY OF MEDICAL SCIENCES AND HEALTH SERVICES)   SUMMER 2009 , Volume 16 , Number 2 (SN 52); Page(s) 45 To 49.
 
Paper: 

STUDY OF HOSPITAL RECORDS REGISTRATION IN TEACHING HOSPITALS OF HAMADAN UNIVERSITY OF MEDICAL SCIENCES IN 2009

 
 
Author(s):  SEYF RABIEI M.A., SEDIGHI IRAJ*, MAZDEH M.D., DADRAS F., SHOKOUHI SOLGI M., MORADI A.
 
* DEPARTMENT OF PEDIATRICS, SCHOOL OF MEDICINE HAMADAN UNIVERSITY OF MEDICAL SCIENCES & HEALTH SERVICES, HAMADAN, IRAN
 
Abstract: 

Introduction & Objectives: Hospital records are representative evidences of medical team activities. In this study, we analyzed hospital records in Hamadan teaching hospitals to find out the problem extent and possible solutions for the problem.
Materials & Methods: In a cross-sectional study, hospital records from teaching hospitals were gathered and put in check lists. We used convenient sampling from all departments, so that by referring to hospital achieve, all new discharged cases from different wards were extracted. We used a 16 item check list which targeted some basic questions like: admission order, discharge order, early and final diagnosis and so on. In each case perfect answer was registered in yes or no boxes. Collected data were analyzed by SPSS16 hardware.
Results: We achieved the following results after analyzing 457 records from 4 teaching hospitals; there were admission note in 94% of the patients' files. 93% of physicians and residents had signed the orders. 88% of the history sheets were being signed by medical students and/or residents. Differential diagnoses were present in only 75% of cases. Final diagnoses were found in 90% and discharge notes in 84% of the files. 86% of physicians had recorded therapeutic and/or surgical procedures. Para clinical procedure recordings were present in 83% of the files. Only 63% of residents and/or interns had signed their progress notes. And nursing papers were signed in 99% of records. There was exact counseling information in 83% of the files which needed to be consulted; meanwhile 82% of the consulted files had been signed by physicians.
Conclusion: This study shows that, there are important defects in hospital records. It seems that there are multiple factors contributing to the problem, such as overcrowding of the hospitals, careless medical students and the most important factors are insufficient training about the problem.

 
Keyword(s): DATA REGISTRATION, HAMADAN UNIVERSITY OF MEDICAL SCIENCES, HOSPITAL RECORDS
 
References: 
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