بررسي ميزان رعايت اصول تشخيص نويسي در پرونده هاي باليني بيماران بستري در بيمارستان هاي شهر كاشان در سال 1381

Surveying the principle of diagnosis recording in patientsʹ medical records of Kashan hospitals in 1381

Background: With respect to the importance of recording diagnosis in patientsʹ medical data for educational, research and legal and statistic aspects, we designed a study on patientsʹ medical records that were hospitalized in Kashan ʹs hospitals in 1381. Material and methods: This study was performed on medical files of 51 specialists working in Kashan University of Medical Sciences. Totally, 1071 medical records which were selected randomly, averagely 21 records for each physician, were included. We used the list of standard principle of International Classification of Disease (ICD-10). Data extracted and separated according to each hospital and clinical field. Results: Data were recorded correctly in diagnosis, orders, and external events, 87%, 77%, and 65%, respectively. The rate of diagnosis records were in its high level in Matini hospital (92%), and were in lowest range in Naqavi hospital. The rate of order records were 95% in Shahid Beheshti and in lowest range in Naqavi hospital (72.9%). The rate of principle of external events records were in highest range in Shahid Beheshti hospital (77.8%) and in lowest range in Matini hospital (50%). Conclusion: We found the rate of recording level was good. It is correlated with attention of specialist and supervisor of medical data committee of university.