Quantitative Evaluation and Observance of Legal Components of Medical Records of Patients in Selected Hospitals in Mashhad in the First Quarter of 2018

In the health system, medical records have different uses such as follow-up, education, research, profession supporting patients, physicians, and health facilities, as well as evaluating health services, so poor documentation of medical records can lead to low quality of care and low quality of analysis results. The aim of this study was quantitative evaluation and observance of legal components of medical records of patients in selected hospitals in Mashhad in the first quarter of 2018.

In this descriptive study was reviewed 442 medical records from 4 teaching hospitals of Mashhad University of Medical Sciences in the first quarter of 2018 using a researcher-made checklist composed of two parts forms completeness and legibility and the second part observing the legal components in 9 main forms. The data were analyzed using Excel software using descriptive statistics methods.

The results showed that the highest rate of completion was in the forms of postoperative care, physician orders, and anesthesia and the lowest rate of completion was in history, admission, and discharge summary forms. Surgical forms including operation reports, postoperative care, and preoperative care were more legible than others, and f doctor's orders and nursing report forms were less legible. Observing of legal components revealed 65.58 percent of forms were documented in Persian language and 72.51 percent were manually documented.Conclusion Improving the quality of data and documentation is very important for the treatment team, care continuity, and patient safety in medical centers. Increasing awareness about the importance of medical records completion, proper design of forms to ease data entry, monitoring medical records completion, nonstop assessment of factors affecting forms completion, planning, and implementation of an operational plan to improve documentation could be recommended as a solution.