文章基本信息

标题：The Effect of Medical Recording Training on Quantity and Quality of Recording in Gynecology Residents of Tabriz University of Medical Sciences
本地全文：下载
作者：Manizheh Sayyah-Melli ; Malahat Nikravan Mofrad ; Abolghasem Amini 等
期刊名称：JOURNAL OF CARING SCIENCES
印刷版ISSN：2251-9920
出版年度：2017
卷号：6
期号：3
页码：281-292
DOI：10.15171/jcs.2017.027
语种：English
出版社：TABRIZ UNIVERSITY OF MEDICAL SCIENCES, FACULTY OF NURSING AND MIDWIFERY
摘要：Introduction: Medical records contain valuable information about a patient's medical history and treatment. Patient safety is one of the most important dimensions of health care quality assurance and performance improvement. Completing the process of documentation is necessary to continue patient care and continuous quality improvement of basic services. The aim of the present study was to evaluate the effect of medical recording education on the quantity and quality of recording in gynecology residents of Tabriz University of Medical Sciences. Methods: This study is a quasi-experimental study and was conducted at Al-Zahra Teaching Hospital, Tabriz, Iran, in 2016. Thirty-two second through fourth year gynecologic residents of Tabriz University of Medical Sciences who were willing to participate in the study were included by census sampling and participated in training workshop. Three evaluators reviewed the residents’ records before and after training course by a checklist. Statistical analyses were performed using SPSS 13 software. P-values less than 0.05 were considered statistically significant. Results: The results showed that before the intervention, there were significant differences in the quantity of information status among the evaluators and no significant difference was observed in the recording of qualitative status. After the workshop, among the 3 evaluators, there were also significant differences in the quantity of data recording status; however, no significant change was observed in recording of qualitative status. Conclusion: The study findings revealed that a sectional training course of correct and standardized medical records has no effect on reforming the process of recording.
关键词：Medical record; Education; Iran