نشریه مدیریت اطلاعات سلامت
سال نهم شماره 1 (پیاپی 23، فروردین و اردیبهشت 1391)

The information on nutritional status as a part of patient's medical information should be documented on patient records by dietitians. Despite the importance of this information in the process of decision making and medical care and even legal aspects, no proper attention has so far been paid to documenting such information on patient records. This study aimed to design a prototype patient nutrition record (PNR) and implement it in teaching hospitals to determine its validity, efficacy and acceptability.

This applied study was conducted in 2010-2011 in two steps. First, 6 forms of PNR including nutritional history sheet (in 2 pages), food frequency questionnaire (FFQ), daily nutritional status evaluation report, diet order sheet, parental/tube feeding order sheet, were designed. The forms were then implemented for 121 patients in endocrinology and internal medicine, pediatric, and orthopedic wards of two academic hospitals in Iran (Golestan Hospital in Ahwaz and Namazi Hospital in Shiraz) for a period 4 months. The opinions of 118 medical staff members on the implementation were collected by a questionnaire. The validity of the questionnaire was verified by academic experts and its reliability was confirmed by Cronbach's alpha. The obtained data was analyzed by descriptive statistics, analysis of variance (ANOVA) and independent t-test.

Mean scores of questions about the content and importance of nutritional information of the PNR and the implementation of the PNR were 4.14 and 4.1, respectively. No statistically significant differences between responses to questions and the hospitals, the type of career (medical specialist, nutritionist, and nurse), and the wards could be confirmed.

Medical care practitioners that participated in this study accepted the prototype PNR. They confirmed that the high importance of integrating a PNR in patient records.

The integrated educational system and service provision have involved the managers of Iranian universities of medical sciences in different tasks and limited their access to adequate information for decision making. Hence, it seems to be vital to adopt plans in order to provide necessary information for decision making. The current study was carried out to define the role of research and development units in management information system of selected universities of some countries in order to apply these experiences to Iranian universities of medical sciences.

This comparative, cross-sectional study was conducted in 2010. First, the theoretical foundations, the available records and related literature were studied. The status of research and development system was then investigated in 8 international universities. Data was collected by observing websites and performing supplementary interviews with the aforementioned institutions. The main research variables included the tasks, objectives and key processes of the unit. Finally, data was analyzed and compared using comparative tables.

The most significant roles of research and development units included providing and analyzing accurate information by conducting necessary studies at the appropriate time, supporting the decision and the policy making processes, improving the quality of activities, upgrading universities, providing an appropriate image of the university by giving relevant statistics and information, and facilitating cooperation with counterpart units in other universities.

With regard to the key role of research and development units in university management information systems, Iranian universities of medical sciences are proposed to take corrective actions if they lack a fully efficient research and development unit.

Deductions are a part of hospital revenues. However, they mostly remain unpaid due to incorrect documentation. This study focused on the rate and causes of deductions made by hospitals affiliated to Kashan University of medical Sciences, Kashan, Iran, according to available documents.

This was a descriptive cross-sectional study conducted in the first half of 2009 in hospitals of Kashan University of Medical Sciences. The research population included 7907 medical records covered by the Social Security Insurance. The data was collected by a standard checklist. It was then analyzed through descriptive statistics.

Based on available documents, the most important causes of deductions were lack of a physician's order in drug forms (427), lack of laboratory report in laboratory forms (2195), lack of radiology report in radiology forms (226), incorrect operation report in surgery forms (429), lack of an anesthesiologist's signature in anesthesia forms (322), and lack of consultation order in consultation forms (226). The study also showed that in general, among all evaluated forms, drug forms had the maximum of deductibles.

The most frequent cause of deductions is incorrect documentation. On the other hand, insurance organizations only pay costs according to registered data. Therefore, it is really essential and helpful to pay enough attention to documentation principles. In addition, it is important to use diagnosis related group (DRG) and healthcare information systems.