Manizheh Sayyah-Melli
1*, Malahat Nikravan Mofrad
2, Abolghasem Amini
3, Zakieh Piri
4, Morteza Ghojazadeh
5, Vahideh Rahmani
61 Departement of Obstetrics and Gynecology, Shahid Beheshti University of Medical Sciences, School of Medical Education, Tehran, Iran
2 Departement of Nursing, School of Nursing & Midwifery, School of Medical Education, Shahid Beheshti University of Medical Sciences, Tehran, Iran
3 Department and Center for Educational Research and Development (EDC), Tabriz University of Medical Science, Tabriz, Iran
4 Department of Medical Records, Tabriz University of Medical Sciences, Tabriz, Iran
5 Research Center of Evidence-Based Medicine, Tabriz University of Medical Sciences, Tabriz, Iran
6 Women's Reproductive Health Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
Abstract
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.