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Paper Information

Journal:   HEALTH INFORMATION MANAGEMENT   AUGUST-SEPTEMBER 2012 , Volume 9 , Number 3; Page(s) 370 To 381.
 
Paper: 

EFFECTS OF INCLUDING A BRIEF DISEASE PROGRESS COLUMN IN PHYSICIAN ORDER SHEETS OF HOSPITAL DOCUMENTS ON IMPROVED RECORDING OF DISEASE PROGRESS

 
 
Author(s):  ESMAEILI DOOKI MOHAMMAD REZA*, SORKHI HADI, FATEMI SEYED ABBAS, HOSSEINZADEH FATEMEH, ZAHEDPASHA YADOLLAH, TAMADDONI AHMAD, NAKHJAVANI NAEIMEH, BARARI SAVADKOHI RAHIM, MOHAMMADZADEH IRAJ, SALEHIOMRAN MOHAMMAD REZA, AHMADPOUR KACHO MOUSA, HADIPOOR ABBAS, OSIA SOHEIL, HAJIAHMADI MAHMOUD, BIJANI ALI, MAHMOODI NESHELI HASSAN, ESHRAGHI PEIMAN, BABAZADEH KAZEM, MOHAMMADPOUR MIR ALI
 
* NON-COMMUNICABLE PEDIATRIC DISEASES RESEARCH CENTER, BABOL UNIVERSITY OF MEDICAL SCIENCES, BABOL, IRAN
 
Abstract: 

Introduction: Medical records consist of documents evidencing a patient’s health status at a moment of life. There is a close relationship between disease progress and daily physician orders issued in medical records. Each order in fact reflects the patient’s medical status and his/her disease progress. In this study, while keeping the previous progress page in the records, a column of brief disease progress was included in physician order sheets to increase the quality of records and promote the education of learners.
Methods: In this cross-sectional controlled interventional study, medical records of all patients admitted to super specialty wards of Amirkola Children Hospital during the first quarters of 2009 and 2010 were included. From a total of 3462 records, 150 records were studied each year. Each indicator of disease progress, which was recorded based on subjective, objective, assessment, and plan (SOAP) note, was given a score. Finally, if only three indicators were mentioned in the record, it was considered as poor. Scores 4-5 represented moderate and scores 6-7 were considered as good. The scores of the records were then compared using statistical tests including t-test, paired t-test, Pearson’s correlation coefficient, chi-square test, Fisher’s exact test, and Kappa coefficient. P values less than 0.05 were considered as significant.
Results: The mean number of physician orders in records during the first quarters of 2009 and 2010 were respectively 9.15±10.8 and 8.45±6.80 cases. Good scores had the highest frequency in the new brief disease progress form. The highest average of results in the studied groups was observed in brief disease progress notes of 2010. Comparison of mean scores revealed statistically significant differences (P<0.05).
Conclusion: Adding a new column named “brief disease progressive note” in physician order sheets significantly promoted the recording of disease progress and reasons for medical orders based on SOAP note. Therefore, it is recommended to include this column in physician order sheets.

 
Keyword(s): MEDICAL RECORDS, PROGRESSIVE NOTE, PHYSICIAN ORDER SHEET, DOCUMENTATION
 
 
References: 
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Click to Cite.
APA: Copy

ESMAEILI DOOKI, M., & SORKHI, H., & FATEMI, S., & HOSSEINZADEH, F., & ZAHEDPASHA, Y., & TAMADDONI, A., & NAKHJAVANI, N., & BARARI SAVADKOHI, R., & MOHAMMADZADEH, I., & SALEHIOMRAN, M., & AHMADPOUR KACHO, M., & HADIPOOR, A., & OSIA, S., & HAJIAHMADI, M., & BIJANI, A., & MAHMOODI NESHELI, H., & ESHRAGHI, P., & BABAZADEH, K., & MOHAMMADPOUR MIR, A. (2012). EFFECTS OF INCLUDING A BRIEF DISEASE PROGRESS COLUMN IN PHYSICIAN ORDER SHEETS OF HOSPITAL DOCUMENTS ON IMPROVED RECORDING OF DISEASE PROGRESS. HEALTH INFORMATION MANAGEMENT, 9(3), 370-381. https://www.sid.ir/en/journal/ViewPaper.aspx?id=403687



Vancouver: Copy

ESMAEILI DOOKI MOHAMMAD REZA, SORKHI HADI, FATEMI SEYED ABBAS, HOSSEINZADEH FATEMEH, ZAHEDPASHA YADOLLAH, TAMADDONI AHMAD, NAKHJAVANI NAEIMEH, BARARI SAVADKOHI RAHIM, MOHAMMADZADEH IRAJ, SALEHIOMRAN MOHAMMAD REZA, AHMADPOUR KACHO MOUSA, HADIPOOR ABBAS, OSIA SOHEIL, HAJIAHMADI MAHMOUD, BIJANI ALI, MAHMOODI NESHELI HASSAN, ESHRAGHI PEIMAN, BABAZADEH KAZEM, MOHAMMADPOUR MIR ALI. EFFECTS OF INCLUDING A BRIEF DISEASE PROGRESS COLUMN IN PHYSICIAN ORDER SHEETS OF HOSPITAL DOCUMENTS ON IMPROVED RECORDING OF DISEASE PROGRESS. HEALTH INFORMATION MANAGEMENT. 2012 [cited 2021May12];9(3):370-381. Available from: https://www.sid.ir/en/journal/ViewPaper.aspx?id=403687



IEEE: Copy

ESMAEILI DOOKI, M., SORKHI, H., FATEMI, S., HOSSEINZADEH, F., ZAHEDPASHA, Y., TAMADDONI, A., NAKHJAVANI, N., BARARI SAVADKOHI, R., MOHAMMADZADEH, I., SALEHIOMRAN, M., AHMADPOUR KACHO, M., HADIPOOR, A., OSIA, S., HAJIAHMADI, M., BIJANI, A., MAHMOODI NESHELI, H., ESHRAGHI, P., BABAZADEH, K., MOHAMMADPOUR MIR, A., 2012. EFFECTS OF INCLUDING A BRIEF DISEASE PROGRESS COLUMN IN PHYSICIAN ORDER SHEETS OF HOSPITAL DOCUMENTS ON IMPROVED RECORDING OF DISEASE PROGRESS. HEALTH INFORMATION MANAGEMENT, [online] 9(3), pp.370-381. Available: https://www.sid.ir/en/journal/ViewPaper.aspx?id=403687.



 
 
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