are the medical records of high quality in teaching hospitals?
نویسندگان
چکیده
background: objective: method the results were reported in ratios (%) averages and standard deviation. t-test was used to examine the association of length of stay and records data adequacy scores. data was analysed by the spss software data was analysed by the spss software data was analysed by the spss software results: conclusion: key words : documentation , medical records , review , teaching hospitals , tabriz patient records had many deficiencies. instructions for documentation are necessary. regular monitoring and evaluation by the attending physicians and writing skills education could be effective in accurate documentation. journal of medical education summer 2004;5(2):51-54 completeness of the patient records was moderately acceptable (68.7%). the difference between performance of residents, interns and students in documentation of primary diagnoses and differential diagnoses was significant (p without summary sheet. the study was descriptive and 100 patient records were selected through random sampling. records were related to the patients who had been discharged from the general internal ward during april to june 2000. data was collected using the questionnaire including 30 closed questions, and 5 open ones. . to determine documentation of patient records at the internal medicine ward of imam khomeini hospital, tabriz, iran. : documentation of medical data in patient records is needed to improve the quality of healthcare and medical knowledge progress. documentation of patient history, clinical problems, treatment, and follow-up care are needed to improve practice and research.
منابع مشابه
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عنوان ژورنال:
journal of medical educationجلد ۵، شماره ۲، صفحات ۰-۰
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