بررسی وضعیت ثبت اطلاعات در پرونده های بیماران دیابتی مراکز آموزشی و درمانی شهرستان ساری در سال 1385

Background and purpose: The core of the health information system in the hospitals lies within medical records. Ït is a means of communication between the care providers. Good medical record documentation is essential for effective clinical care. This study is designed to evaluate the condition of documentation of the data for diabetic patients and its effect on treatment in educational hospitals of Mazandaran Üniversity of Medical Sciences through the years 2006 and 2007. Materials and methods: This is a descriptive study and the subjects recruited were medical records of diabetic patients from Ïmam Khomeini and Bou Âli educational hospitals in Sari Çity, Ïran 2006-2007. The collected data were analyzed using SPSS software version 17. Results: Ôf total 270 diabetic records, 16 records (5.92%) belonged to Ïnsulin-dependent diabetes mellitus (ÏDDM), 14 records (5.19%) to non-insulin-dependent diabetes mellitus (NÏDDM), 50 records (18.52%) to gestational diabetes and 190 records (70.37%) to unidentified type of diabetes. 201 patients (74.44%) were women and 69 (25.56%) were men and of 227 patients 84.7% were married. Çonclusion: Despite of efforts made in recent years in context of improving the documents of admitted patients and contrary to all practical training that physicians received on the basis of basic requirements for international classification of diseases (ÏÇD), still, there are major problems in record of main data. We conclude that more attention must be paid by medical administrators, physicians and medical record staffs to this matter. We suggest health authorities must reform the system of recording and more training courses must be funded to improve involving staffs’ awareness.