مقایسه‌ ی کیفیت مستندات پرونده‌های پزشکی بیماران بستری در بیمارستان‌های عمومی دانشگاه علوم پزشکی ایران و تامین اجتماعی شهر تهران : 1386

Introduction: Quality of patients care is directly linked with medical documentation quality, because in all medical professions related to patient care, quality of decisions depends on information quality. Thus, in this study two main populations that offer medical care in country, Ministry of Health (MoH) and Social security Organization, were selected to measure access rate, and level of medical care professions to quality data that including data accuracy, relevancy, definition, timeliness and data representation format. So we will present clear point of view of health information condition in own country to related masters and decisions. Unfortunately so far no research has be done to show facts of information quality in our health societies. Methods: This research is a comparative study conducted in April to October 2007. Multistage sampling performed for general hospitals of IUMS and Social Security, of which two hospitals were selected randomly. Research populations include discharge medical records of inpatients (about 31000 records) in general hospitals of IUMS (Hazrate Rasoul Akram and Firouzgar Hospitals) and Social Security (Shahid Fayazbakhsh and Ayatollah Kashani Hospitals). Then sample size allocated to each hospital was selected in centralized retrospective manner. So, 153 records for Hazrate Rasoul Akram hospital, 47 for Firouzgar hospital, 133 for Shahid Fayazbaksh hospital and 67 for ayatollah Kashani hospital were selected. Information was collected through direct observation by a checklist with 37 questions and five sections for any quality elements, reliability of which had been measured by specialists and the validity by test-retest method. Collected data analyzed by SPSS software for descriptive statistics and analytical statistics (t-test and chi-square). Results: Our study showed that regard rate mean of data quality elements in documents of IUMS is as below: Data accuracy 92/02 % ‚ relevancy 85/84% ‚ definition 85/87 % ‚ timeliness 78/2% and data representation format 82/87 and in Social Security hospitals: 87/65% ‚ 75/54 % ‚ 82/06% ‚ 88/3% and 80/75% respectively. Conclusion: Regard rate of data quality elements of accuracy‚ relevancy‚ definition and data representation format in IUMS shows higher percentage and mean. But documentation of social security medical record about quality timeliness element has higher level as compared with IUMS t-test analysis shows that in accuracy, relevancy and timeliness of quality elements there is a significant difference, but no significant difference in definition and data representation format quality elements. Considering the differences between our findings with ideal situation (100 percent), for improving quality of documented information in medical records, it is necessary to set national rules by health authorities for complete and quality documentation by documentarian of medical records. Also, legal supports of professional medical records staff for performing quality and quantity control of medical records documentation.