ميزان آگاهي و عملكرد دستياران و دانشجويان پزشكي دانشگاه علوم پزشكي سمنان نسبت به مستندسازي مراقبت هاي ارايه شده به بيمار از ديدگاه پزشكي قانوني

Medical assistants and studentsʹ knowledge and practice rate of Semnan Medical Sciences University regarding documentation of cares provided to patient from medicolegal aspect.

Background and aim: One of the factors that a physician can not defend himself in claims is uncompleted medical files of patient. This study was done to evaluate the knowledge and practice rate of medical assistants and students in Semnan Medical University. Materials and Methods: This descriptive analytical study was performed to study the knowledge and practice rate of 134 medical assistants and students regarding medical documentation of provided care. A twelve section questionnaire and a checklist were used after confirming their validity and reliability. Data was gathered by interviewing with assistants and medical chart review. Findings: The results showed that 40% of assistants knew legal aspects of documentation, 25.2% of them knew how to use abbreviations in final diagnosis and surgeries. 14.2% knew duration of confirmation of verbal orders. The relationship between knowledge and educational course was significant (p<0.05) Only 10% completed the medical chart legally. Most of assistants tended to record clinical data. There was a significant relationship between practice, education course and knowledge (p<0.05) Conclusion: According to the results, the knowledge and practice were weak. Process of clinical education must be evaluated in outpatient and inpatient wards.