بررسی میزان آگاهی، نگرش و عملکرد دانشجویان پزشکی نسبت به اصول پرونده نویسی در مراکز آموزشی درمانی دانشگاه علوم پزشکی و خدمات بهداشتی درمانی مازندران در سال 1383

Background and Objectives: History, clinical findings, procedures undertaken, and patients response to treatment are written in clinical records, hence their contents are indicators of physicians’ evaluation. If clinical records are provided precisely, clear and systematized, they indicate the clinical thinking of the staff and facilitate patients diagnosis process. These records have an important role in coordinating professional staff involved in patient care. Since the physicians and medical students are involved more in medical records documentation than the other hospital staff, thus, a study on their knowledge, attitude and practice towards the principles of medical records documentation is undertaken. Materials and Methods: This is a descriptive study, which is done about the rate of knowledge, attitude and practice of 207 Medical students of Mazandaran University of Medical Sciences in university hospitals. Descriptive and inferential statistical analytic methods were used for the collected data. For comparison of the hospitals, regarding observing designed principals in the completion of medical files, according to the filled questionnaires the minimum and maximum score designated as 1-5 which is very poor to excellent. Then the mean score was calculated and considered for the comparison of hospitals. For the determination of the relationship between knowledge, attitude, and practice, β Kendall’s Tau Test was used. Results: The majority of the participants had low knowledge (77.8%) about medical records documentation. Most of them did not have good attitude (54.1) about completion of medical records and significance and value of medical records documentation in treatment, education, and research. Conclusion: Results indicate that incompletion of medical records at the university affiliated hospitals are due to lack of awareness of the students towards the method of medical records documentation. In addition, not considering the completion of records in evaluation of the students can affect their practice.