Medical Records in Kerman Medical University Hospitals

Abstract

Introduction: Medical record service as a major index in medical and health sciences is a reliable tool to show activity output and treatment quality. In this study, medical record functions in different fields such as admission, medical archive, coding and statistics were investigated, evaluated and compared.

Methods: This was a cross-sectional study carried out in 2002. The dada were collected by four checklists with 119 questions as well as forms, which were filled out according to 1300 patients' medical files. The data collecting tool was designed according to standards of American Medical Record Association (1990) and standard form of Ministry of Health, Education and Treatment (1996). SPPS software was used to analyze the data with chi-square and Kruskal-Wallis tests.

Result: The findings of the research showed that the quality of medical record services in investigated hospitals is much lower than that of national and international standards. The findings also showed that the quality of medical record service in Giroft and Bam (Mehdieh) were low, in Kerman Darman, Shafa and Davazdah Farvardin were average and in Imam Khomeini hospital, Kashani (Baft), Beheshti, Sina, Imam Reza and Vali-Asr were fairly good. Bahonar hospital had the best quality in medical record service. Total score of medical record function in investigated hospitals was fairly good (61% of total scores) compared with other hospitals in Iran.

Conclusion: The function of medical record service can be promoted by official announcements, duty determination and personnel's encouragement to follow the instructions as well as hiring well-trained staff.