Related Factors in Medical Records Documentation Quality and Presenting Solutions from Managers' and Physicians' Viewpoints Occupied in Hospitals Affiliated to Kashan University of Medical Sciences

Introduction: Medical record documentation is an important legal and professional requirement for all health professionals which ensures holistic patient care presented to him. The aim of this study was to deter-mine factors affecting documentation quality from the viewpoints of managers and physicians in Kashan University of Medical Sciences and present solutions. Methods: This descriptive cross-sectional study was performed through census in which all managers and physicians employed in universities affiliated to Kashan University of Medical Sciences participated (n=300). The study tool was a questionnaire made by the researcher including questions on effects of factors such as knowledge, attitude, and procedures and standards and follow up and supervision on documentation quality, which was completed by study population after evaluating its reliability and validity. Data, was analyzed by SPSS software using descriptive analytic statistics indices. Results: Among the factors affecting documentation quality, factors of knowledge and attitude respectively enjoyed the highest mean score (94.3) and after that, factors of follow up and supervision (90.1) were placed and factors of processes and standards got the mean score of 88.5 finally. Regarding presented solutions, the recommended strategies for follow up and supervision were more effective (90.6) and resolutions for processes and standards were less effective than others. There was a significant difference among different groups under investigation. Conclusion: Among the factors affecting documentation quality, the factors of knowledge and attitude enjoy the most affectivity on document quality. Therefore, it is recommended to hold training courses for the medical staff for teaching documentation, putting emphasis on reward/punishment factors, evaluating documentation staff based on their documents and computerizing health data entry.