Evaluation of the Quality of Documentation in Medical Records: Defects, Causes and Solutions

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.