Evaluation of the Effect of Presence of Health Information Technology Expert on Medical Records of Patients Admitted to Fatemeh Zahra Hospital, Sari, Iran

Background: Documenting medical records plays an important role in treatment and prevention. The purpose of this study was to evaluate the impact of the presence of health information technology experts in clinical wards on the documentation of hospital admissions files. Methods: In this descriptive cross-sectional study, 96 inpatient records in 2014 and 96 inpatient records in Fatemeh Zahra Hospital in Sari were reviewed. Data were collected based on a checklist based on the layout of the data elements in the four main admission sheets, file summary, history and course of the disease. Data entry was defined with yes value of one, no value of zero and no use value of 2. Overall evaluation of the documentation rate was considered as 95-100% “good”, 75-94% moderate and below 75% poor. Using the sample size formula, 192 files were analyzed in a multi-stage (i.e. simple random and stratified) manner. Data were analyzed by SPSS 21 software. Results: The results showed that the total registration of all four forms in 2013 was about 51.01% and in 2017 was 62.92%. The impact of information technology on the process of admission forms, file summary, history and course of illness was 88.25, 85.63, 31.09, and 84.30% in the middle class, respectively. Among the data categories, the highest mean of authentication was recorded (91.7%) in four forms. Conclusion: Documentation rate after recruitment of health information technology experts in clinical wards increased by 11.91%. In order to achieve a good situation of recruiting trained personnel in clinical wards of hospitals, it is necessary to create a suitable framework for implementation and development of information technology in order to achieve maximum efficiency in health systems.