بررسی تطبیقی استانداردهای مدارک پزشکی در کشورهای منتخب با ایران

Introduction: Challenges relating to expense and quality has induced an atmosphere in a way that decision makers at all levels are investigating objective data to evaluate healthcare organizations. Since medical records document the care of the patients, and are considered to be the first yard stick to evaluate the care rendered to the patients, His essential that they follow certain rules and regulations, so that the quality of services offered by this department be computable with and durable to evaluative standards. Methods: In this descriptive comparative study, standards of medical records in the United States, Australia, and Canada were gathered and compared with the Iranian standards, via fax, internet and email. Findings: Research findings show that the Iranian Ministry of Health and Medical education has taken in to consideration the minimum standards relating to medical records policies and procedures. All countries under study except Iran had standards for education and professional development. Iran is the only country that the use of computer and other technological gadgets were used without defining their objectives for use. Results: With a glimpse at the importance of the role that standards play in facing the challenge of expense and quality in today's health care system, It is essential that medical records as part of the system, abide by a standard and follow on efficient system. But due to constraints and shortages in standards prescribed by the ministry, a national movement in standardization of different medical records with the help of experts in this field seems essential.