Volume 23, Issue 3 (10-2020)
jha 2020, 23(3): 30-41 |
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Salmanizadeh F, Ameri A, Khajouei R, Mirmohammadi M. The extent of deficiencies in the main forms of patients' medical records by the role of documentarians. jha 2020; 23 (3) :30-41
URL: http://jha.iums.ac.ir/article-1-3326-en.html
URL: http://jha.iums.ac.ir/article-1-3326-en.html
1- PhD Student, Faculty of Management and Medical Information Science, Kerman University of Medical Sciences, Kerman, Iran.
2- Ms.c. of Health Information Technology, Faculty of Management and Medical Information Science, Kerman University of Medical Sciences, Kerman, Iran.
3- Associate Professor, Faculty of Management and Medical Information Science, Kerman University of Medical Sciences, Kerman, Iran. ,r.khajouei@kmu.ac.ir
4- Director of Statistics and Information Technology, Shafa Hospital, Kerman University of Medical Sciences, Kerman, Iran.
2- Ms.c. of Health Information Technology, Faculty of Management and Medical Information Science, Kerman University of Medical Sciences, Kerman, Iran.
3- Associate Professor, Faculty of Management and Medical Information Science, Kerman University of Medical Sciences, Kerman, Iran. ,
4- Director of Statistics and Information Technology, Shafa Hospital, Kerman University of Medical Sciences, Kerman, Iran.
Abstract: (3175 Views)
Introduction: Despite the implementation of hospital information system, in some countries, medical records are still documented in traditional ways. Incomplete documentation in medical records can lead to inappropriate medical decisions and higher costs. The purpose of this study was to investigate the deficiencies of the main forms in medical records by the role of documentarians.
Methods: This cross-sectional study was conducted in Shafa hospital in Kerman in 2019-2020. The medical records of this hospital were randomly selected. The completion or non-completion of data elements in the main forms of medical records was examined using a valid and reliable checklist. The collected data were analyzed using descriptive statistics in SPSS 24.
Results: The result of this study demonstrated that 34.70% of the selected records for each patient were incomplete. In most forms, ward secretaries did not complete the relevant data elelments. In other forms, nurses and physicians did not complete more than half of the data elelments. The highest number of deficiencies were observed in the electrocardiogram attachment sheets, emergency records, and radiographic request forms, respectively.
Conclusion: Some data elements such as demographic information, initial diagnosis, final diagnosis, and signatures were not completed by ward secretaries, physicians, and nurses. Non-completion of data elements may lead to problems in providing services to patients. Evaluating the extent of medical record deficiencies based on the role of documentarians can be effective in modifying the forms and developing future training programs.
Methods: This cross-sectional study was conducted in Shafa hospital in Kerman in 2019-2020. The medical records of this hospital were randomly selected. The completion or non-completion of data elements in the main forms of medical records was examined using a valid and reliable checklist. The collected data were analyzed using descriptive statistics in SPSS 24.
Results: The result of this study demonstrated that 34.70% of the selected records for each patient were incomplete. In most forms, ward secretaries did not complete the relevant data elelments. In other forms, nurses and physicians did not complete more than half of the data elelments. The highest number of deficiencies were observed in the electrocardiogram attachment sheets, emergency records, and radiographic request forms, respectively.
Conclusion: Some data elements such as demographic information, initial diagnosis, final diagnosis, and signatures were not completed by ward secretaries, physicians, and nurses. Non-completion of data elements may lead to problems in providing services to patients. Evaluating the extent of medical record deficiencies based on the role of documentarians can be effective in modifying the forms and developing future training programs.
Type of Study: Research |
Subject:
Health Information Management
Received: 2020/08/17 | Accepted: 2020/10/1 | Published: 2020/10/1
Received: 2020/08/17 | Accepted: 2020/10/1 | Published: 2020/10/1
References
1. Mahmoodian S, Alidadi F, Arji G, Ramezani A. Evaluation of completeness and legal aspectscompliance of emergency's medical records in teaching hospitals of zabol university of medical sciences. J Paramed Sci Rehabil. 2014;3(1):33-9. [In Persian]
2. Greger J, Williams BA. Billing for outpatient regional anesthesia services in the United States. Int Anesthesiol Clin. 2005;43(3):33-41. [DOI:10.1097/01.aia.0000166187.45449.44]
3. Neville TH, Tarn DM, Yamamoto M, Garber BJ, Wenger NS. Understanding factors contributing to inappropriate critical care: A mixed-methods analysis of medical record documentation. J Palliat Med. 2017;20(11):1260-6. [DOI:10.1089/jpm.2017.0023]
4. de Lusignan S, Hague N, Brown A, Majeed A. An educational intervention to improve data recording in the management of ischaemic heart disease in primary care. J Palliat Med. 2004;26(1):34-7. [DOI:10.1093/pubmed/fdh104]
5. Mamykina L, Vawdrey DK, Stetson PD, Zheng K, Hripcsak G. Clinical documentation: composition or synthesis? J Am Med Inform Assoc. 2012;19(6):1025-31. [DOI:10.1136/amiajnl-2012-000901]
6. Saranto K, Kinnunen UM. Evaluating nursing documentation-research designs and methods: systematic review. J Adv Nurs. 2009;65(3):464-76. [DOI:10.1111/j.1365-2648.2008.04914.x]
7. Saravi BM, Asgari Z, Siamian H, Farahabadi EB, Gorji AH, Motamed N, et al. Documentation of medical records in hospitals of Mazandaran university of medical sciences in 2014: a quantitative study. Acta Inform Med. 2016;24(3):202-206. [DOI:10.5455/aim.2016.24.202-206]
8. Adereti CS, Olaogun AA. Use of electronic and paper‐based standardized nursing care plans to improve nurses' documentation quality in a Nigerian teaching hospital. Int J Nurs Knowl. 2019;30(4):219-27. [DOI:10.1111/2047-3095.12232]
9. Sammer CE, Lykens K, Singh KP, Mains DA, Lackan NA. What is patient safety culture? a review of the literature. J Nurs Scholarsh. 2010;42(2):156-65. [DOI:10.1111/j.1547-5069.2009.01330.x]
10. Rothman B, Leonard JC, Vigoda MM. Future of electronic health records: implications for decision support. Mt Sinai J Med. 2012;79(6):757-68. [DOI:10.1002/msj.21351]
11. Alkhatlan H. Contribution of electronic medical record system to the improvement of safety and quality in clinical practice as perceived by intensive care physicians. Assiut Sci Nurs J. 2019;7(19):1-8. [DOI:10.21608/asnj.2019.67857]
12. Ahmadian L, Nejad SS, Khajouei R. Evaluation methods used on health information systems (HISs) in Iran and the effects of HISs on Iranian healthcare: a systematic review. Int J Med Inform. 2015;84(6):444-53. [DOI:10.1016/j.ijmedinf.2015.02.002]
13. Murphy BJ. Principles of good medical record documentation. J Med Pract Manage 2001; 16(5): 258-260.
14. Jones-Diette J, Robinson NJ, Cobb M, Brennan ML, Dean RS. Accuracy of the electronic patient record in a first opinion veterinary practice. Prev Vet Med. 2017;148: 121-6. [DOI:10.1016/j.prevetmed.2016.11.014]
15. McEvoy D, Gandhi TK, Turchin A, Wright A. Enhancing problem list documentation in electronic health records using two methods: the example of prior splenectomy. BMJ Qual Saf. 2018;27(1):40-7. [DOI:10.1136/bmjqs-2017-006707]
16. Vigoda MM, Lubarsky DA. The medicolegal importance of enhancing timeliness of documentation when using an anesthesia information system and the response to automated feedback in an academic practice. Anesth Analg. 2006;103(1):131-6. [DOI:10.1213/01.ane.0000221602.90315.49]
17. Klein DO, Rennenberg RJ, Koopmans RP, Prins MH. Adverse event detection by medical record review is reproducible, but the assessment of their preventability is not. PloS One. 2018;13(11):1-11 [DOI:10.1371/journal.pone.0208087]
18. Michel P, Quenon JL, de Sarasqueta AM, Scemama O. Comparison of three methods for estimating rates of adverse events and rates of preventable adverse events in acute care hospitals. Br Med J. 2004;328(7433):199. [DOI:10.1136/bmj.328.7433.199]
19. Panagioti M, Khan K, Keers RN, Abuzour A, Phipps D, Kontopantelis E. Prevalence, severity, and nature of preventable patient harm across medical care settings: systematic review and meta-analysis. Br Med J. 2019; 366: l4185. [DOI:10.1136/bmj.l4185]
20. Tavakoli N. Causes of uncompleted medical records, manager and physicians suggestion in hospitals of Isfahan 2004. Health Inf Manage. 2005; 2(1): 15-24. [In Persian]
21. Balaghafari A, Siamian H, Aligolbandi K, Zakeezadeh M, Kahooei M, Yazdani Charati J, Rashida S. A study on the rate of knowledge, attitude and practice of medical students towards method of medical records documentation at Mazandaran university of medical sciences affiliated therapeutic and teaching centers 2003. J Mazandaran Univ Med Sci. 2004; 15(49): 73-80. [In Persian]
22. Seyf Rabiei M, Sedighi I, Mazdeh M, Dadras F, Shokouhi Solgi M, Moradi A. Study of hospital records registration in teaching hospitals of Hamadan university of medical sciences in 2009. Avicenna J Clin Med. 2009; 16(2): 45-9. [In Persian]
23. Mahjoob M, Farahabbadi M, Dalir M. Evaluation of randomly selected completed medical records sheets in teaching hospitals of Jahrom university of medical sciences, 2009. J Fasa Univ Med Sci. 2011; 1(1): 20-8. [In Persian]
24. Babaee A, Salavati F, Tavakoli N, Tavakoli R, Raiesi M, Golmohammadi F. et.al. Frequency of documentation in admission and summary sheet in 3 private, governmental and insurance hospitals in 2002. Health Inf Manage, 2004; 1(1): 10-4. [In Persian]
25. Solomon DH, Schaffer JL, Katz JN, Horsky J, Burdick E, Nadler E, et al. Can history and physical examination be used as markers of quality? an analysis of the initial visit note in musculoskeletal care. Medical care. 2000;38(4): 383-91. [DOI:10.1097/00005650-200004000-00005]
26. Ministry of Health & Medical Education. Main forms and emergency medical records [Internet]. 2011 [Updated 2020 Sep 29; cited 2020 Sep 29]; Available from: https://arakmu.ac.ir/vct/fa/regulation/.
27. Mehraeen E, Raeissi P, Omid Kohan Shoori Z, Ahmadi P, Jani Iranadgan S, Saravani S. Review of medical records documentation in obstetrics and gynecology ward (data quantitative analysis on obstetrics and gynecology ward). Adv Nurs Midwifery. 2015; 24(87):37-44. [In Persian]
28. Dibaee A, Sadati N, Nokhbe A. Knowledge of residents about medical consent sheet in Golesatn Hospital 2009. Sci J Forensic Med. 2011; 2(17): 95-102. [In Persian]
29. Kimiafar K, Vafaee Najar A, Sarbaz M. Quantitative investigation of inpatients' medical records in training and social security hospitals in Mashhad. J Paramed Sci Rehabil. 2015; 4(1):58-67. [In Persian]
30. Bryant G, DeVault K, Ericson C, Garrett G, Haik W, Holmes R, et al. Guidance for clinical documentation improvement programs. J AHIMA. 2010; 81(5):45.
31. Rashida SSh, Kabirzadeh A. Documentation in inpatient with TB in Razi hospital of Ghaemshahr. Health Inf Manage. 2013; 9(6): 786-91. [In Persian]
32. Rangraz J, Ahmadi M, Sadoughi F, Gohari M. Precision and accuracy of death certification data in Kashan Shahid Beheshti hospital. Health Inf Manage. 2010; 7(2): 128-35. [In Persian]
33. Skurka MF. Organization of medical record department in hospital.2nd ed. New York: American Hospital Publishing Inc. 1988.
34. Burke HB, Sessums LL, Hoang A, Becher DA, Fontelo P, Liu F, et al. Electronic health records improve clinical note quality. J Am Med Inform Assoc. 2015; 22(1):199-205. [DOI:10.1136/amiajnl-2014-002726]
35. Neri PM, Redden L, Poole S, Pozner CN, Horsky J, Raja AS, et al. Emergency medicine resident physicians' perceptions of electronic documentation and workflow: a mixed methods study. Appl Clin Inform. 2015; 6(1):27-41. [DOI:10.4338/ACI-2014-08-RA-0065]
36. Nguyen L, Bellucci E, Nguyen LT. Electronic health records implementation: an evaluation of information system impact and contingency factors. Int J Med Inform. 2014; 83(11):779-96. [DOI:10.1016/j.ijmedinf.2014.06.011]
37. Lorenzetti DL, Quan H, Lucyk K, Cunningham C, Hennessy D, Jiang J, et al. Strategies for improving physician documentation in the emergency department: a systematic review. BMC Emerg Med. 2018; 18(1):36. [DOI:10.1186/s12873-018-0188-z]
38. Triplet JJ, Momoh E, Kurowicki J, Villarroel LD, yee Law T, Levy JC. E-mail reminders improve completion rates of patient-reported outcome measures. JSES Open Access. 2017; 1(1):25-8. [DOI:10.1016/j.jses.2017.03.002]
39. Wilbanks BA, Berner ES, Alexander GL, Azuero A, Patrician PA, Moss JA. The effect of data-entry template design and anesthesia provider workload on documentation accuracy, documentation efficiency, and user-satisfaction. Int J Med Inform. 2018; 118:29-35. [DOI:10.1016/j.ijmedinf.2018.07.006]
40. Baumann LA, Baker J, Elshaug AG. The impact of electronic health record systems on clinical documentation times: a systematic review. Health Policy. 2018; 122(8):827-36. [DOI:10.1016/j.healthpol.2018.05.014]
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