Hospital Compliance with Clinical Documentation Standards: A Descriptive Study in two Iranian Teaching Hospitals

Background and Objectives: Standard clinical documentation is an integral part of quality patient care. This study aimed to explore compliance of two Iranian teaching hospitals with the clinical documentation standards.   Methods: A total of 400 records were surveyed. Data were collected using a checklist of standard measures. The checklist comprised 15 items selected from relevant guidelines from either the American Health Information Management Association or Iranian Ministry of Health and Medical Education. Data were analyzed using descriptive statistics.   Findings: On average, 50.2% of medical records were provided in high compliance with standard measures, 26.4% in moderate compliance, and 23.4% in non-compliance. The average highest frequency of compliance with documentation standard was received by “Only blue ink is used for writing” (92%), followed by “Consent forms are completed” (79%) and “Highlighter pen or correction pen is avoided” (71%). The average lowest frequency of compliance with standards was identified for “Admission form is typed and inserted as first page” (0.5%) followed by “Unusable elements for patient are mentioned” (0.75%), and both “Error corrections (if any) are signed and dated by the editor.” (2.52%), and “Cause of error reporting (if any) is mentioned.” (2.52%).   Conclusions: Our results indicated an unsatisfactory level of compliance with clinical documentation standards in the studied hospitals. In addition, some of the lowest rated measures were related to documentation of errors in data recording and their subsequent correction, which can potentially lead to adverse patient outcome or legal consequences. Hence, our study provides further evidence for the urgency of developing strategies to improve commitment of Iranian hospitals to clinical documentation standards.