To search, Click below search items. |
| All Published Papers Search Service |
|
|
|
Title |
The Role of Accreditation in Improving Documentation of Medical Records: A Case Study in Besat Hospital, Hamadan University of Medical Sciences- Iran |
|
Author |
Hassan Ebrahimpour Sadagheyani, Hamid Bouraghi, Parviz Shahmirzalou, Tooba Mehrabi, Ali Mohammadpour |
| Citation |
Vol. 19 No. 3 pp. 81-86 |
|
Abstract |
Problem Despite of the importance of medical records and their documentation, unfortunately, the documentation of medical records has no desirable quality. What is already known about the topic Physicians do not value the documentation of information about the care process, and do not consider the documentation of medical records as a part of care process and this is the most important reason for the incomplete medical records. What this paper adds The accreditation standards have a positive impact on the documentation status of medical records. Abstract Background: Medical records, as legal and professional documents, are valuable tools for accrediting hospitals and all hospitals seek to identify factors that contribute to the improvement of these records by taking into account accreditation standards. Aim: This study aimed to investigate the role of accreditation of health centers in improving the documentation status of records of patients admitted to Besat Hospital affiliated to Hamadan University of Medical Sciences. Methodology: The present analytical and cross-sectional research was conducted in 2018 on records of admitted patients during 2011 and 2017. To this end, the research investigated 1500 records (700 medical record from the second half of 2011 and 800 medical records from the second half of 2017). A researcher-made checklist was used to collect data that was analyzed by SPSS V.22. Findings: All selected forms had a relative improvement after the accreditation of documentation status (P<0.001). The highest score of documentation belonged to the admission and discharge summary from. The lowest score of documentation belonged to the progress notes sheet (24.61%) before the accreditation, and the clinical form header (52.92%) after accreditation. Furthermore, the unit summary sheet had the greatest change (40.5%) and the admission and discharge summary sheet had the lowest change (5.34%). Conclusion: In general, accreditation standards had a positive impact on the documentation status of medical records however, monitoring the implementation of standards and their achievement certainly depended on executive, organizational, human, and cultural factors. Therefore, hospitals should pay special attention to these factors and implement guidelines for documentation of medical records. |
|
Keywords |
Medical record Documentation Accreditation Accreditation Standards Hospitals |
|
URL |
