Documentation of Medical Records by Physicians in the Hospitals under Ardabil University of Medical Sciences, 2001

With respect to the importance of observing principles of documentation of medical records for educational, treatment, research, legal and statistical uses, the correct, complete and timely registration of this information can play a crucial role in the production of necessary data for these kinds of researches. This study was performed to investigate the process of documentation of medical records of the patients in hospitals under Ardabil university of medical sciences. In this research 370 medical records from eight hospitals under Ardabil university of medical sciences were studied. In each hospital samples were selected randomly based on the number of patients hospitalized in one year. Then according to admission and discharge sheets a certain checklist was completed. The information under study included dignosis, treatment, surgery, cause of the accident, patient condition on dircharge, postdischarge advice and cause of death (whether recorded or not) which were identified in the check list. The data were analyzed by SPSS using descriptive statistics. The findings showed that primary, interim and final diagnosis and treatment measures were recorded 71.9%, 58.9%, 60.8% and 52% respectively in the records studied. Althougt 12.7% of these patients were hospitalized dueto accidents, damage and poisoning, only in 8.5% of them the external causes were recorded. In 68% of the records, condition on discharge and in 76.3% of them recommendation on discharge had not been recorded. 3.5% of the records were related to dead patients, but only in 31% of them the main cause and in 8% underlying cause of death was recorded. In general, in 5 2.4% of these records the correct methods of medical recording were not observed by physicians. The results indicated that the process of documentation of medical record by physicians as the main presenters of health care services was performed incompletely. This can lead to the loss of valuable information about the hospitalized patients. It can also have negative impacts on the course of therapy. As a result, the authorities, physicans and specialists in medical recording should pay special attention to this problem.