A STUDY ON THE FREQUENCY OF MEDICAL HISTORY SHEET, OPERATION REPORT SHEET AND PHYSICIAN ORDER SHEET COMPLETENESS BY DIFFERENT DOCUMENTARIES IN ISFAHAN TEACHING HOSPITALS, 2007-8

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SETAREH M.; BAGHERIAN MAHMOUD ABADI H.; AMINI FATEMEH; RAFATI Y.A.; ARJMANDKIA A.

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Journal: Iranian Journal of Forensic Medicine Year:2010 | Volume:4 | Issue:4 (56) Page(s): 244-251

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Title

A STUDY ON THE FREQUENCY OF MEDICAL HISTORY SHEET, OPERATION REPORT SHEET AND PHYSICIAN ORDER SHEET COMPLETENESS BY DIFFERENT DOCUMENTARIES IN ISFAHAN TEACHING HOSPITALS, 2007-8

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Keywords

MEDICAL RECORDSQ2

DOCUMENTATIONQ3

STANDARDQ3

STANDARD OF MEDICAL RECORDQ3

Abstract

Background & Aim: MEDICAL RECORDS DOCUMENTATION is used for maintenance of patient’s legal rights, providing information for research, medical education, general studies and qualitative surveys. MEDICAL RECORDS DOCUMENTATION often renders after medical care accomplishment; therefore, it may be led to deficiency in DOCUMENTATION. In this study the completeness of medical history sheet, operation report sheet and physician order sheet by different documentaries in Isfahan teaching hospitals at 2007-8 was studied.Materials & Methods: This is a descriptive and perspective study. Statistical population is composed of the inpatient MEDICAL RECORDS pertinent to the patients referred to Isfahan teaching hospitals in 2007-8. About 1067 records selected for this survey. The tool of data collection is checklist. By using SPSS (Version10) and Microsoft office excel 2003 the data were analyzed.Findings: Average of personality data registration in medical history sheet, physician order sheet and operation report sheet by department's secretaries was 57, 56 and 64 percent. Average of clinical data registration by physician in medical history sheet was 44 percent. Average of surgical data registration in operation report sheet by surgeon was 71 percent. Average of data registration by operation room's nurse in operation report sheet was 42 percent. Average of physician order data in physician order sheet by physician was 79 percent.Conclusion: According to the findings average of observance medical data registration in Isfahan teaching hospitals was unfavorable. This deficiency is due to different reason such as medicals record documentaries negligence, lack of adequate education for documentaries and shortage of time for completing data by documentaries.

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APA: Copy

SETAREH, M., BAGHERIAN MAHMOUD ABADI, H., AMINI, FATEMEH, RAFATI, Y.A., & ARJMANDKIA, A.. (2010). A STUDY ON THE FREQUENCY OF MEDICAL HISTORY SHEET, OPERATION REPORT SHEET AND PHYSICIAN ORDER SHEET COMPLETENESS BY DIFFERENT DOCUMENTARIES IN ISFAHAN TEACHING HOSPITALS, 2007-8. SCIENTIFIC JOURNAL OF FORENSIC MEDICINE, 4(4 (56)), 244-251. SID. https://sid.ir/paper/53616/en

Vancouver: Copy

SETAREH M., BAGHERIAN MAHMOUD ABADI H., AMINI FATEMEH, RAFATI Y.A., ARJMANDKIA A.. A STUDY ON THE FREQUENCY OF MEDICAL HISTORY SHEET, OPERATION REPORT SHEET AND PHYSICIAN ORDER SHEET COMPLETENESS BY DIFFERENT DOCUMENTARIES IN ISFAHAN TEACHING HOSPITALS, 2007-8. SCIENTIFIC JOURNAL OF FORENSIC MEDICINE[Internet]. 2010;4(4 (56)):244-251. Available from: https://sid.ir/paper/53616/en

IEEE: Copy

M. SETAREH, H. BAGHERIAN MAHMOUD ABADI, FATEMEH AMINI, Y.A. RAFATI, and A. ARJMANDKIA, “A STUDY ON THE FREQUENCY OF MEDICAL HISTORY SHEET, OPERATION REPORT SHEET AND PHYSICIAN ORDER SHEET COMPLETENESS BY DIFFERENT DOCUMENTARIES IN ISFAHAN TEACHING HOSPITALS, 2007-8,” SCIENTIFIC JOURNAL OF FORENSIC MEDICINE, vol. 4, no. 4 (56), pp. 244–251, 2010, [Online]. Available: https://sid.ir/paper/53616/en

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