EVALUATION OF RANDOMLY SELECTED COMPLETED MEDICAL RECORDS SHEETS IN TEACHING HOSPITALS OF JAHROM UNIVERSITY OF MEDICAL SCIENCES, 2009

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MAHJOB MOHAMMAD PARSA; FARAHABADI SEYYED MOHAMMAD EHSAN; DALIR MAHSA

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Journal: JOURNAL OF ADVANCED BIOMEDICAL SCIENCES Year:2011 | Volume:1 | Issue:1 Page(s): 20-28

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Title

EVALUATION OF RANDOMLY SELECTED COMPLETED MEDICAL RECORDS SHEETS IN TEACHING HOSPITALS OF JAHROM UNIVERSITY OF MEDICAL SCIENCES, 2009

Author(s)

MAHJOB MOHAMMAD PARSA | FARAHABADI SEYYED MOHAMMAD EHSAN | DALIR MAHSA | Issue Writer Certificate

Keywords

MEDICAL RECORDSQ2

DOCUMENTATION OF SHEETSQ2

TEACHING HOSPITALQ3

Abstract

Background and objective: Medical record documentation, often use to protect the patients legal rights, also providing information for medical researchers, general studies, education of health care staff and qualitative surveys is used. There is a need to control the amount of data entered in the medical record sheets of patients, considering the completion of these sheets is often carried out after completion of service delivery to the patients. Therefore, in this study the prevalence of completeness of medical history, operation reports, and physician order sheets by different documentaries in Jahrom TEACHING HOSPITALs during year 2009 was analyzed.Methods and Materials: In this descriptive/retrospective study, the 400 medical record sheets of the patients from two TEACHING HOSPITALs affiliated to Jahrom medical university was randomly selected. The tool of data collection was a checklist based on the content of medical history sheet, operation report and physician order sheets. The data were analyzed by SPSS (Version10) software and Microsoft Office Excel 2003.Results: Average of personal (Demography) data entered in medical history, physician order and operation report sheets which is done by department's secretaries were 32.9, 35.8 and 40.18 percent. Average of clinical data entered by physician in medical history sheet is 38 percent. Surgical data entered by the surgeon in operation report sheet was 94.77 percent. Average of data entered by operation room's nurse in operation report sheet was 36.78 percent; Average of physician order data in physician order sheet entered by physician was 99.3 percent.Conclusion: According to this study, the rate of completed record papers reviewed by documentary in Jahrom TEACHING HOSPITALs were not desirable and in some cases were very weak and incomplete. This deficiency was due to different reason such as medical record documentaries negligence, lack of adequate education for documentaries, High work load and shortage of time for completing data by documentaries.

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APA: Copy

MAHJOB, MOHAMMAD PARSA, FARAHABADI, SEYYED MOHAMMAD EHSAN, & DALIR, MAHSA. (2011). EVALUATION OF RANDOMLY SELECTED COMPLETED MEDICAL RECORDS SHEETS IN TEACHING HOSPITALS OF JAHROM UNIVERSITY OF MEDICAL SCIENCES, 2009. JOURNAL OF ADVANCED BIOMEDICAL SCIENCES, 1(1), 20-28. SID. https://sid.ir/paper/204035/en

Vancouver: Copy

MAHJOB MOHAMMAD PARSA, FARAHABADI SEYYED MOHAMMAD EHSAN, DALIR MAHSA. EVALUATION OF RANDOMLY SELECTED COMPLETED MEDICAL RECORDS SHEETS IN TEACHING HOSPITALS OF JAHROM UNIVERSITY OF MEDICAL SCIENCES, 2009. JOURNAL OF ADVANCED BIOMEDICAL SCIENCES[Internet]. 2011;1(1):20-28. Available from: https://sid.ir/paper/204035/en

IEEE: Copy

MOHAMMAD PARSA MAHJOB, SEYYED MOHAMMAD EHSAN FARAHABADI, and MAHSA DALIR, “EVALUATION OF RANDOMLY SELECTED COMPLETED MEDICAL RECORDS SHEETS IN TEACHING HOSPITALS OF JAHROM UNIVERSITY OF MEDICAL SCIENCES, 2009,” JOURNAL OF ADVANCED BIOMEDICAL SCIENCES, vol. 1, no. 1, pp. 20–28, 2011, [Online]. Available: https://sid.ir/paper/204035/en

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