بررسی میزان تکمیل شدن گزارش‌های الکترونیکی بیمار در بیمارستان‌های دانشگاه علوم پزشکی سمنان

Background and Aim: Nearly a decade has passed since the use of computers to record patients' medical records in Iran. Despite the advantages of computer systems, healthcare providers are reluctant to use them therefore, parts of computerized records will be incomplete, which lead to information gaps. The purpose of the present study is to investigate the completion of electronic reports and its reasons from employees' viewpoint. Materials and Methods: In this descriptive study, 2499998 electronic reports were evaluated using a checklist that examined types of identity and clinical data meanwhile, staff’s attitudes were investigated by a researcher-made questionnaire. The validity of the questionnaire was confirmed by experts and its reliability was estimated through test-retest method. Results: The results showed that 100% of some clinical and identity data were not recorded. Some 58.7% of staff members reported the absence of clear regulations and 54.7% reported inappropriate electronic forms as the reasons. Some 24.1% of staff members suggested the codification of clear guidelines and 15.6% offered surveillance programs as solutions to completing electronic reports. Conclusion: The staff reported human and organizational factors as the most important elements influencing the quality of electronic reports. It seems that the following are among the solutions which can remove many defects of electronic reports: investment in education, management support for the codification of relevant policies, health information technology professionals' participation in designing electronic forms, and the use of high technologies to record data for busy employees.