The extent of deficiencies in the main forms of patients' medical records by the role of documentarians

Abstract

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.