وضعیت ثبت داده در پرونده‌ی بیماران بستری مبتلا به سل در مرکز آموزشی درمانی رازی قائمشهر

Abstract

Introduction: The health information system of hospitals depends on their medical records. Therefore, the detailed documentation, and maintenance of patient records can lead to timely diagnosis and effective treatment of diseases in any country, and should be included in the strategic program for disease control. This study aimed to determine the status of the documentation of tuberculosis patients in Razi Hospital of Ghaemshahr in 2010. Methods: This research is a description of the existing data in patient records. The study population consisted of all records of hospitalized tuberculosis patients in 2010 in the Razi Hospital of Ghaemshahr. The 66 patients were studied by using checklist, admission documents, papers, briefs, history, course of illness, prescriptions, and pathology, radiology, and laboratory reports. The checklist had formal validity based on data elements in the records. Data were analyzed by SPSS for Windows (version 16). Results: The results showed that from a total of 66 records of patients with tuberculosis, in the admission document and the final diagnosis in 25 cases (8.37%) the diagnosis was not stated and in 7 cases (6.10%) phrases such as BK+ were recorded. No action was recorded in the measures section of any of the records (0%). However, documents such as surgery, radiology, and ultrasound reports show that diagnostic and therapeutic procedures, such as 5 cases of bronchoscopy, 4 cases of endoscopies and biopsies, 22 cases of CT scan of the lungs, intubation, dialysis and etcetera, have been undertaken. Conclusion: Much effort has been devoted to improving documentation of outpatients’ and inpatients’ data, and to classification of diseases. However, many problems still exist in this respect. This was a teaching hospital; therefore, training physicians on data documentation is a necessity. Keywords: Tuberculosis; Documentation; Medical Records; Record; Information