بررسي ميزان ثبت اطلاعات در پرونده بيماران اورژانس در بيمارستانهاي كاشان بهار 1381

Completion rate of data information in emergency record in Kashan ʹs hospitals

Background: Emergency department has a vital role for dealing with life and death situation. Monitoring and evaluating the quality of care issues with an accurate and adequate data information system is of utmost importance. The aim of this study was to determine the rate of data information which was documented in emergency record in two hospitals of Kashan city. Materials and Methods: In spring 2002, this existing type data study was performed, 540 records were selected through simple random sampling. Data collection was based on legal, administrative and financial issues as well as personnel who were responsible to complete the data (physicians, nurses and administrative unit). Results: The survey has revealed that 14%, 12%, 14% of legal, administrative, and financial issues were remained undocumented. Meanwhile, 17% of admission-related, 11% of nursing-related and 17% of medical-related documents were uncompleted. The highest rate of documented data was achieved by nurses and the lowest belonged to physicians. There were significant statistical differences between two hospitals for type of issues and personal, time of discharge, external causes and orders to discharge, where the lowest elements were completed. Conclusions: The rate of documented information in emergency records of these two hospitals was comparatively good; however, some documentation items such as time of discharge, recommendations in discharge would need to be improved.