The Effect of Filling the Patient Records by Physicians, According to the Instructions, on Incompleteness of Medical Records at Ziaeian Hospital, Tehran, Iran

The full and timely documentation of medical records plays an important role in the improvement of medical, legal, educational, treatment and research processes. Incomplete record keeping is indicative of defective care and treatment. The purpose of this study was to determine the effect of implementation of the instructions on filling the patient's records by physicians on the incompleteness of medical records of Ziaeian Hospital, Tehran, Iran.
This descriptive applied study was carried out at Ziaeian Hospital in 2016. The study population included 2413 medical files filled out in August and December. The sample included 324 incomplete medical files from August (before the implementation) and 288 incomplete medical records in December (after implementation). The medical record checklist was used to collect data. SPSS and Wilcoxon signed-rank tests were employed for data analysis.
The mean number of defects was 12.4 and 9.9 before and 9.9 after the intervention, respectively. Number of defects in the admission document (P = 0.012), counseling request (P = 0.048), surgery report (P = 0.001), case summary (P = 0.001) and anesthesia (P = 0.012) showed a significant reduction in the number of defects and the effectiveness of the intervention. However, in total medical record documentation, the intervention was not effective (P = 0.238).
It appears that reducing the defects in medical records of Ziaeian Hospital has not been significant which can affect the treatment of patients, the quality of transmission of information and also use of medical records by legal authorities. The results of this research can be useful for hospital directors and managers for a more optimal planning approach.