Documentation of Emergency Medical Records Based on Educational Accreditation in Educational Hospitals of Mazandaran University of Medical Sciences

Emergency medical services (EMS) are among the major concerns in health care. Documentation of patient care in medical records format is of great importance since they are used in further treatments, assessment of care, medical-legal reports, and medical educations.  

This descriptive cross-sectional research was performed by studying the emergency records available in five educational centers affiliated with Mazandaran University of Medical Sciences, 2018. A checklist was compiled based on a guideline for EMS records recommended by Iran Ministry of Health and Medical Education. Values 1 and 2 were considered for data recorded and not recorded, respectively. In cases of no valuable data a value of 0 was considered. Four hundred fifty files were selected using the sample size formula. Data were analyzed in SPSS V21 applying descriptive statistics.

The overall rate of emergency medical records was 62% and was considered poor. Among the centers studied, Qaemshahr Razi Hospital (74%) and Sari Imam Khomeini Hospital (68%) had the highest rates of medical records in EMS.

According to this study, documentation of EMS records was poor. So, recording data should be monitored on a regular basis in all hospitals in Iran and training sessions on this issue should be held for physicians as well as admission and nursing staff.