Background & Objective : Inpatient information is the best source for researches, medical education, process of patient treatment and legal organizations. Moreover, correct, complete and ontime registration of this information can play a crucial role in the production of necessary data for these kinds of researches. Regarding the importance of the issue, in this study we evaluated the quality and quantity of these data in the hospitals under Ardabil University of Medical Sciences.
Methods : In this research 370 rcords from eight hospitals of Ardabil were studied. In each hospital samples were selected randomly based on the number of patients hospitalized in one year. Then according to admission and discharge sheets a certain check list, was completed. The information under study including demography, admission and discharge, inter-hospital and inter-ward transfer, diagnosis, treatment, surgery, death of the patients and authentications (recorded or not) were identified in the check list. The data were analyzed using descriptive statistics.
Results : The results showed that sex, marital status, date and place of birth had not been recorded in 5.9%, 15.7%, 2.4%, 51.6% of records respectively. Primary, interim and final diagnosis and treatment measures were not recorded about 28.1%, 41.1%, 39.2% 48% of the patients respectively. Although 13% of these patients were hospitalized due to accidents, impairments and poisoning, only in 8.5% of them the external causes were recorded. At 68.6% of the records, condition on discharge and at 76.3% of them recommendation on discharge had not been recorded. 3.5% of records related to dead patients, but only in 31%, main cause and in 8% underlying couse of death was record. 25% of the studied records were not coded. 13.7% of existing codes did not match the final diagnosis .At 52.4% of these records the correct method of writing diagnosis was not observed by physicians and at 36.5% coding had not been done carefully.
Conclusions : The results indicated that the process of medical recording by health care services was performed deficiently and this leads to the loss of valuable information about the hospitalized patients. As a result, the authorities, physicians and specialists in medical recording should pay special attention to this problem. Physicians and specialitists of medical record to this problem were necessary.