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Volume 15, Issue 4 (2010) |
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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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Abstract: (20538 Views) |
| 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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Type of Article: Research Article |
Received: 2010/08/10 | Accepted: 2020/06/10 | ePublished: 2020/06/10
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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. Iran J Forensic Med 2010; 15 (4) :244-251 URL: http://sjfm.ir/article-1-243-en.html
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