The Effect of Educational Intervention on Medical Diagnosis Recording among Residents in Kashan University of Medical Sciences

Studies indicate that using interventions including education may improve medical record documentation and decrease incomplete files. Since, physicians play a crucial role in medical record documentation, the researchers aimed to examine the effect of educational intervention on observing principles of medical diagnosis recording among residents in Kashan University of Medical Sciences. This quasi-experimental study was conducted in 2010 on 19 specialty residents (from internal medicine, obstetrics and gynecology, and surgery) in Kashan University. During a 5-hour workshop, guidelines for recording diagnostic information related to surgery, obstetrics and internal medicine were taught. Before and after the intervention, five medical records from each resident were assessed using a checklist which was designed based on diagnostic information related to each discipline. Data were analyzed through paired t and Wilkoxson test. There was no improvement in recording obstetric diagnoses (type of delivery, place of delivery, outcome of delivery, complication of delivery) after the training. Also training did not have any effect on documentation of underlying cause and clinical manifestations of diseases by internal medicine residents and surgery residents (P=0.285 and P=0.584). Administering an educational intervention alone did not improve recording of diagnosis among residents. It seems that to have complete, accurate and high quality medical recording requires interaction we should consider other solutions, including three main key components, namely, management, health information management professionals and health care providers. Therefore, developing such an interaction is recommended.