TITLE

What they fill in today, may not be useful tomorrow: lessons learned from studying Medical Records at the Women hospital in Tabriz, Iran

AUTHOR(S)
Pourasghar, Faramarz; Malekafzali, Hossein; Kazemi, Alireza; Ellenius, Johan; Fors, Uno
PUB. DATE
January 2008
SOURCE
BMC Public Health;2008, Vol. 8 Issue 1, p139
SOURCE TYPE
Academic Journal
DOC. TYPE
Article
ABSTRACT
Background: The medical record is used to document patient's medical history, illnesses and treatment procedures. The information inside is useful when all needed information is documented properly. Medical care providers in Iran have complained of low quality of Medical Records. This study was designed to evaluate the quality of the Medical Records at the university hospital in Tabriz, Iran. Methods: In order to get a background of the quality of documentation, 300 Medical Records were randomly selected among all hospitalized patient during September 23, 2003 and September 22, 2004. Documentation of all records was evaluated using checklists. Then, in order to combine objective data with subjective, 10 physicians and 10 nurses who were involved in documentation of Medical Records were randomly selected and interviewed using two semi structured guidelines. Results: Almost all 300 Medical Records had problems in terms of quality of documentation. There was no record in which all information was documented correctly and compatible with the official format in Medical Records provided by Ministry of Health and Medical Education. Interviewees believed that poor handwriting, missing of sheets and imperfect documentation are major problems of the Paper-based Medical Records, and the main reason was believed to be high workload of both physicians and nurses. Conclusion: The Medical Records are expected to be complete and accurate. Our study has unveiled that the Medical Records are not documented properly in the university hospital where the Medical Records are also used for educational purposes. Such incomplete Medical Records are not reliable resources for medical care too. Some influencing factors external to the structure of the Medical Records (i.e. human factors and work conditions) are involved.
ACCESSION #
51485909

 

Related Articles

  • Part I: Introduction.  // Registered Nurse: Journal of Patient Advocacy;Sep2009, Vol. 105 Issue 7, Special section p1 

    The article offers information on the integration of technology in medical care in the U.S. It states that health information technology (HIT) offers a universal healthcare solution for healthcare industries. It cites that many hospitals are adopting technology to their patient care processes,...

  • To what extent are adverse events found in patient records reported by patients and healthcare professionals via complaints, claims and incident reports? Christiaans-Dingelhoff, Ingrid; Smits, Marleen; Zwaan, Laura; Lubberding, Sanne; van der Wal, Gerrit; Wagner, Cordula // BMC Health Services Research;2011, Vol. 11 Issue 1, p49 

    Background: Patient record review is believed to be the most useful method for estimating the rate of adverse events among hospitalised patients. However, the method has some practical and financial disadvantages. Some of these disadvantages might be overcome by using existing reporting systems...

  • The Problem--Oriented Medical Synopsis. Gledhill, V. X.; Mackay, I. R.; Mathews, J. D.; Strickland, R. G.; Stevens, D. P.; Thompson, C. D. // Annals of Internal Medicine;May73, Vol. 78 Issue 5, p685 

    Describes the application of the Problem-Oriented Medical Synopsis approach to medical records in a hospital medical ward and patient care. Principles of the problem-oriented medical synopsis; Procedure on patient's admission and discharge; Mechanism used during assessment of patient in hospital.

  • how do we engage the medical staff in IT? Glaser, John // hfm (Healthcare Financial Management);Oct2005, Vol. 59 Issue 10, p118 

    The article focuses on the need for healthcare organizations and hospitals in the United States to increase investments in clinical information systems like computerized provider order entry and electronic health records. Physicians and medical staff need to support clinical information systems...

  • Researchers find key data missing from patient files.  // Modern Healthcare;2/14/2005, Vol. 35 Issue 7, p60 

    Focuses on a study conducted by researchers in Colorado which found out that crucial health information was missing from patient files. Effect of the missing information on patients; Information lacking in some patient files; Respondents of the study.

  • Brief report: Failure of an electronic medical record tool to improve pain assessment documentation. Saigh, Orit; Triola, Marc M.; Link, R. Nathan // JGIM: Journal of General Internal Medicine;Feb2006, Vol. 21 Issue 2, p185 

    Objective: To comply with pain management standards, Bellevue Hospital in New York City implemented a mandatory computerized pain assessment screen (PAS) in its electronic medical record (EMR) system for every outpatient encounter. We assessed provider acceptance of the instrument...

  • Co-morbidity and functional limitation in older patients underreported in medical records in Nordic Acute Care Hospitals when compared with the MDS-AC instrument. Jónsson, Pálmi V.; Finne-Soveri, Harriet; Jensdóttir, Anna B.; Ljunggren, Gunnar; Bucht, Gosta; Grue, Else V.; Noro, Anja; Björnson, Jan; Jonsén, Elizabeth; Schroll, Marianne // Age & Ageing;Jul2006, Vol. 35 Issue 4, p434 

    This article presents a study on the co-morbidity and functional limitation in older patients who were underreported in medical records in Nordic Acute Care Hospitals compared to the Minimum Data Set for Acute Care (MDS-AC) instrument. Materials and methods used in the study are discussed. There...

  • Wiring for Consumers: So Far, So Slow.  // H&HN: Hospitals & Health Networks;Jul2008, Vol. 82 Issue 7, p41 

    The article reveals that the progress in the use of hospital-based personal health records (PHR) and patient portals have been slow, according to the findings of the 2008 Most Wired Survey and Benchmarking Study. Analysis of the study also showed that patients at top tech hospitals, in general,...

  • Study Identifies Steps to EHR Implementation.  // hfm (Healthcare Financial Management);Nov2004, Vol. 58 Issue 11, p25 

    Explores the key challenges to the electronic health records (EHRs) of hospitals in the U.S. Factors needed for full EHR implementation; Necessity of Medicare and Medicaid reimbursement and tax policy incentives to complement direct investment; Web site for more information on the matter.

Share

Read the Article

Courtesy of THE LIBRARY OF VIRGINIA

Sorry, but this item is not currently available from your library.

Try another library?
Sign out of this library

Other Topics