میزان رعایت اصول تشخیص نویسی در پرونده‌های پزشکی بیماران بستری با تشخیص شکستگی بیمارستان مطهری ارومیه

Abstract

Introduction: A patient's medical record is the most important source for medical research, education and law. The physician's role, as the head of the medical team, in registration of accurate information of diagnoses, orders and observations is of utmost importance. This research aimed to determine the rate of adherence to principles of diagnosis recording in medical records of patients with fractures hospitalized at Urmia Motahari Hospital. Methods: This cross-sectional survey was conducted on the records of patients admitted to Urmia Motahari Hospital with a final diagnosis of fracture in 2007. A sample size of 400 records was selected randomly. A checklist was used to determine whether or not the necessary information was recorded. The checklist, the validity and reliability of which have been confirmed, included anatomic site, type, shape (closed or open), external cause and fracture-related injuries. The results were shown as frequency tables. Results: Based on our results, the most recorded item was the site of fracture (97.25%) and the lowest was the shape of fracture (7%). None of records included all items. In addition, only 1.25% of the records contained 4 items. Conclusion: Incomplete recording of final diagnosis in the patient's record is one of the main problems of documentation. Chart writing is one of the most important responsibilities of physicians and medical teams, which, according to our results, is not taken seriously. Chart writing can be improved by workshops. Establishment of rules for documentation can also increase the adherence to principles of documentation. Keywords: Documentation; Medical Records; Inpatient; Fracture; Bone.