Evaluating the Type and Number of Errors in Medical Records Documentation in Tehran Ayatollah Taleghani Hospital

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SHAMS AZAM; ALIMOHAMMADZADEH KHALIL; HOSSEINI SEYED MOJTABA

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Journal Paper

Paper Information

Journal: JOURNAL OF COMMUNITY HEALTH RESEARCH Year:2018 | Volume:7 | Issue:4 Page(s): 242-249

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Title

Evaluating the Type and Number of Errors in Medical Records Documentation in Tehran Ayatollah Taleghani Hospital

Author(s)

SHAMS AZAM | ALIMOHAMMADZADEH KHALIL | HOSSEINI SEYED MOJTABA | Issue Writer Certificate

Keywords

Medical Records

Medical Errors

Documentation

Hospitals

Abstract

Introduction: Recording medical information of hospital records is in fact the Documentation of the medical team activities in the hospital. Therefore, correct, accurate, and timely record of patients' information can play a vital role in improving the educational, medical, research, legal, and statistical activities. This study aimed to investigate the type and number of errors in Medical Records Documentation and its effective factors in Ayatollah Taleghani Hospital. Methods: This descriptive-analytic study was cross-sectional. A sample of 330 patients' records in Ayatollah Taleghani Hospital was investigated through a selfmade checklist. Data were analyzed using the SPSS software and descriptive and analytical methods. Results: The number of errors in the records showed that, among the examined errors, No Specify the type of diagnosis and take medicine Time in more than 50% of the cases were not accurately recorded. The least error was due to the absence of time and stamp. There was a significant relationship between medical record errors and some demographic characteristics. Conclusion: According to the results and the existence of errors in recording files, hospital doctors and nurses' efforts to promote the Documentation of cases were necessary. Rewardingly, some methods, such as initial training of newly arrived residents, encouraging methods, and periodic evaluation of cases can be used.

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APA: Copy

SHAMS, AZAM, ALIMOHAMMADZADEH, KHALIL, & HOSSEINI, SEYED MOJTABA. (2018). Evaluating the Type and Number of Errors in Medical Records Documentation in Tehran Ayatollah Taleghani Hospital. JOURNAL OF COMMUNITY HEALTH RESEARCH, 7(4), 242-249. SID. https://sid.ir/paper/344337/en

Vancouver: Copy

SHAMS AZAM, ALIMOHAMMADZADEH KHALIL, HOSSEINI SEYED MOJTABA. Evaluating the Type and Number of Errors in Medical Records Documentation in Tehran Ayatollah Taleghani Hospital. JOURNAL OF COMMUNITY HEALTH RESEARCH[Internet]. 2018;7(4):242-249. Available from: https://sid.ir/paper/344337/en

IEEE: Copy

AZAM SHAMS, KHALIL ALIMOHAMMADZADEH, and SEYED MOJTABA HOSSEINI, “Evaluating the Type and Number of Errors in Medical Records Documentation in Tehran Ayatollah Taleghani Hospital,” JOURNAL OF COMMUNITY HEALTH RESEARCH, vol. 7, no. 4, pp. 242–249, 2018, [Online]. Available: https://sid.ir/paper/344337/en

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