documentation

Numerous studies conducted in Iran have shown that the quality of documentation of medical records by physicians and medical staff is not very satisfactory. Considering the importance of proper documentation of medical records in teaching hospitals as a valid document of educational and medical activities in educational accreditation, the present study was designed and conducted to investigate the effect of training on the quantity and quality of documentation of  the patients' records.

The present study was an action research study. The status of medical records was first evaluated by residents, interns and externs in 400 randomly selected files. Then, based on an intervention protocol, training programs were held for these individuals and every month defects in the files were reported to the department heads in the form of written feedback. Finally, using SPSS V.22 software, data were analyzed by McNemar's test.

Based on the comparison of the studied criteria before and after the intervention, the percentage of history recording, the percentage of on-service note, the percentage of off-service notes, and the percentage of daily progressive note (PN) in all three groups of medical students including externs, interns and residents improved significantly. (P <0.05). In addition, the intervention significantly improved other indicators, including the principles of recording correct diagnosis in the files, recording the time and date and also  medication orders, completing the patient education form, obtaining informed consent from the patients in case of need, recording medical consultations correctly and preparation of standardized file summary (P <0.05).

Based on the findings, continuous training and providing regular written feedback can be effective in increasing the quantity and quality of recording necessary items in the patients' medical records by residents, interns and externs.

The quality of documentation in medical records is considered as one of the vital components in the provision of healthcare services and it has a profound effect on clinical decision making, the quality of care and ultimately the conclusion of patients' health. However, there are significant shortcomings in this field that can have negative consequences on the health and well-being of patients. Therefore, the present study comprehensively investigated the deficiencies of documentation in medical records, identified the root causes of these deficiencies, and provided effective solutions to improve the quality of documentation.

The present study is a retrospective descriptive-analytical study that was conducted in six private hospitals in Tabriz from March to July 2024. 540 cases were selected using the simple sampling method. The data collection tool was a researcher-made checklist, whose validity and reliability were confirmed by experts. Two focus group meetings consisting of managers, doctors, nurses and health information management specialists were held in order to identify the causes of deficiencies and provide solutions. Data were analyzed using SPSS software version 23 and MAXQDA software version 22.

The findings showed that 72.28% of all records were complete. Among the forms of the reviewed records, the admission and discharge summary form with 98.97% were among the most complete forms and the medical history and physical examination form with 42.27% were among the most incomplete forms. Furthermore, the admission staff had the highest documentation rate (89.51 %) and the medical staff had the lowest documentation rate (42.12 %). The average compliance with completeness of data in the reviewed documents was 71.53%, accuracy and precision of data was 80.71%, timeliness of data was 80.12%, consistency of data was 87.74% and reliability of data was 92.91%. The belief of doctors and paramedics that documentation is not part of the treatment process, the inappropriateness of the structure, content and information in the forms were the main causes of deficiencies. In the field of factors affecting the quality of documentation, there are various factors such as awareness and attitude, follow-up and monitoring, and procedures and standards.

Despite recent efforts to improve clinical documentation, the quality of documentation in some healthcare settings is still not optimal and there are significant problems in the documentation of records. Considering the relationship between the quality of documents and issues such as the continuation of care, the quality of care and legal issues, it is necessary for healthcare settings to investigate the process of documentation of medical records through intervention methods.

One of the most important and controversial roles of nurses is documentation, which is especially of great importance in the emergency department. Patients with a diagnosis of poisoning are one of the most common and challenging emergency department patients, which involve many ethical and legal issues. This research aimed to determine the related factors to the quality of nursing documentation of patients diagnosed with poisoning in the emergency department.

The present research is a cross-sectional study. Sampling among 1402 emergency cases (384 cases) in the first half of the year was done by simple random sampling. In order to collect data, the nursing documentation quality checklist was used with two dimensions’ report writing and medication administration.

The evaluation of the patients’ documents showed that the average and standard deviation of the age of the patients were 29.96 ± 9.93 years and most of the patients (60.2%) were women. The mean and standard deviation of the documentation quality were 8.75 ± 6.82 from the range of -48 to 48. The quality of nursing documentation had a statistically significant relationship with some characteristics of patients, including age, education, history of alcohol consumption, and history of admission to the emergency room.

Based on the findings of the study and considering the importance of nurse documentation as the most important document in judicial authorities, it is necessary to take basic steps to improve the documentation knowledge of nurses in the emergency department and specifically for patients diagnosed with poisoning. It is also necessary to pay more attention to elderly, illiterate patients and those with alcohol consumption.

This study aimed to investigate the performance of senior dental students of the Faculty of Dentistry of Isfahan University of Medical Sciences in the documentation of dental records.

Methods & Materials:

 This cross-sectional study was performed at Isfahan University of Medical Sciences in the Spring of 2021. 200 dental students in their last two years of education participated in this study. A questionnaire was used to examine students’ performance in filling dental records, which included a Likert scale with five options: never, rarely, sometimes, often, and always; A score of 1 to 5 was assigned to each of the answers. Then the results were reported in the form of mean and standard deviation, and with a significance level of 0.05, an independent T-test was used to investigate their relationship with gender and academic year.

The performance of 77% of students was in the range of 2 to less than 4, which was reported as medium performance. Also, 0.5% had poor, and 22.5% had a good performance. Unlike gender, students' performance had a significant relationship with their academic year, so 5th-year students performed better than 6th-year students (p value < 0.001).

According to the findings of the present study, the performance of most of the senior dental students of Isfahan University of Medical Sciences in completing the dental file is at a medium level. It was also seen in this study that the academic year of students, unlike their gender, can affect their performance; So, 5th-year students performed better than 6th-year students.

Introduction:

Accurate documentation of medical records is one of the important issues during the process of diagnosis and treatment of the disease. It is very important in terms of treatment, legal, educational, financial and research. This study aimed to determine awareness of medical students about principles of medical records documentation.

This descriptive-analytical and cross-sectional study was conducted in 2022-2023 at Zahedan university of medical sciences. The research population included medical students in the preclinical, clinical, and residency levels. The sample size was 260 medical students and the sampling method was quota sampling. The data collection tool was a researcher-made questionnaire. The validity and reliability of questionnaire were confirmed. Descriptive statistics (frequency, percentage, mean, and standard deviation) and analytical tests (T-test and One-way ANOVA) were used to analysis the research data.

The average awareness score obtained by the research community was 64.92±14.02 out of 74. The highest and lowest average scores were respectively related to the principles about the time frame of completing the information and the general principles of documenting the medical record. The test of the relationship between the variables of the research showed that only the relationship between the two variables of awareness level and educational level of students was significant.

In this study, the level of students' awareness about the principles of documenting medical records was optimal. But by comparing the different results of this research with previous similar studies, it can be said that teaching the principles of documentation over time has had a positive effect on improving the level of students' awareness.

Continuous evaluation of medical record documentation is needed for a quality patient care. This study aims to evaluate the status of nursing documentation before and after providing feedback to nurses in the emergency department (ED) of a hospital in Mashhad, Iran.

This quasi-experimental study was conducted in the ED of Imam Reza Hospital in Mashhad in 2022. First, the ED nursing documentation assessment tool was developed based on the literature review and its psychometric properties were evaluated. Then, 150 medical records were randomly selected from the ED and examined by this tool. The results of assessment along with the guideline for correct documentation were given to the nurses as feedback in a video format. One month after, 150 medical records were examined again and the results compared. Data were analyzed in SPSS software, version 22 using the independent t-test, chi-square test, and Fisher’s exact test.

Of 22 indicators in the initial draft of designed tool, 18 obtained acceptable CVR (>0.56) and CVI (>0.79). Cronbach’s α coefficient for the designed tool was obtained 0.85. The mean score of nursing documentation before giving feedback was 27.9±2.1 (out of 36) which increased significantly to 29.1±1.6 after giving feedback (P<0.001). The highest percentage of incomplete documentation was related to the triage form and compliance with the principles of correction or addition.

The status of nursing documentation in the ED of study hospital can be improved by the feedback method. It is recommended to regularly evaluate the nursing documentation status in this department and provide feedback to the nurses.

Background &

In the future, the field nursing student will be responsible for managing a ward alone, so having the ability to manage and provide safe care is one of the requirements of this profession. This study was conducted with the aim of comparing the effect of two educational methods on the ability to manage care and to document the provision of safe care in nursing intern students.
Materials &

The number of samples in the first part (retrospective - face-to-face training) was 112 students and in the second part(intermittent-virtual training)169 students had the conditions to enter the research. To collect information, a part of the reliable and valid questionnaire tool "Clinical Competence of Nursing Students in Arena" by Jouzi and colleagues (2014) was used, which included the management dimension of clinical competence. To analyze the data, SPSS 24 software was used at the level of (P>0.05).

The results showed that there was no significant difference in the mean scores of ability in care management and documentation of safe care provision of nursing students in two courses of virtual and face-to-face training (p>0.05).

The nursing intern students in the virtual education course, like the students in the face-to-face course, were able to obtain high grades in terms of their ability to manage care and document the provision of safe care, which shows that the training provided to students during the Corona era was effective in maintaining students' competence.

Clinical coding is a complex and error-prone process. Correct clinical coding requires high-quality documentation of medical records. This study aimed to identify the quality of medical records documentation and the accuracy of coding with ICD-10 compared to ICD-11.

This cross-sectional descriptive study was conducted in 2022. The samples were chosen from 11638 medical records of patients admitted at the Shahid Mohammadi teaching hospital with the diagnosis of injury, poisoning, and certain other consequences of external causes. Using Cochran's formula, 500 medical records were evaluated. The research was conducted in two stages to check the accuracy of coding and the defects in the documentation of medical records for coding. The research data collection tools were separate checklists for each stage. Data were analyzed using descriptive statistics in SPSS software.

The number of codes allocated to the studied medical records was 1673 and 1468 codes based on ICD-10 and ICD-11 classification systems, respectively. The majority of records (98%) had at least one type of major or minor error, 23% had only major errors, 46% had only minor errors, and 31% had both types of ICD-10 coding errors. Moreover, 81% and 26% of the medical records contained adequate information to fully or relatively fully describe the codes using ICD-10 and ICD-11 classification systems, respectively.

Compared to ICD-10, there were more defects in the documentation of medical records for coding with ICD-11. Development written documentation guidelines by ICD-11, using templates and reminders, and providing feedback to healthcare providers. Using automated coding support tools, coding audits, and continuous training of coders are essential for coding quality improvement.

Recording and reporting in nursing is one of the important and valuable tasks in maintaining and continuing care. New models such as the SBAR communication model are important in this regard.

The purpose of this study was to provide a simple overview of how to apply the SBAR communication model in nursing recording and reporting.

This study is based on searching existing library sources and valid databases such as Magi ran, SID, PubMed, IranMedex using common search engines such as Google Scholar with keywords such as Communication Models, methods Documentation Methods and Nursing Reports and Nursing Records are performed.

The results of the study showed that the traditional method of nursing reporting is done in Iran. Communication models such as SBAR are more applicable to patient delivery in the ward. Applying the SBAR communication model in the field of nursing recording and reporting can also be a good way to make more quality records.

Using communication models such as the SBAR model in nursing recording and reporting can optimize the relationship between patient and nurse, improve the quality of nursing services, reduce errors and increase satisfaction in health care recipients.

Discharge summaries (DSs) are among the most important tools for transferring information from hospital physicians to other physicians and play an important role in the continuity of care. Low quality and lack of information are the main problems of DSs, and evaluation of their quality from the physicians' perspective in Iran has rarely been done. This study aimed to evaluate the DSs' quality of content and completeness.

This descriptive cross-sectional study was performed on the DSs of Shafa Hospital in Kerman. A valid and reliable researcher-made questionnaire (α=0.97) was used. This questionnaire had three sections, including questions related to demographic information, evaluation of the quality of DSs (8 questions), and the degree of completeness of the DSs (8 questions).

Out of 110 physicians, 98 (89%) filled out questionnaires. Completeness, awareness, continuity of care, legibility, relevancy, length, consistency, organization, and physicians’ satisfaction were below the average (50%) throughout the hospital. The highest level of physicians' satisfaction with the quality of the content (79.27%) and completeness (77.73%) was attributed to electronic discharge summaries of the neurology department. Organization, legibility, and consistency, respectively, were identified as the best predictors of physicians' satisfaction with the quality of the DSs’ content.

Policymakers should increase the quality of DSs by creating instructions, holding documentation training courses, increasing the supervision of senior physicians on interns and residents, and finally developing electronic automated DSs.