Answers are grounded in this paper and cite their sources.
Cross-sectional study examines documentation quality in medical records, highlighting areas for improvement.
Despite the implementation of hospital information system, in some countries, medical records are still documented in traditional ways. Incomplete documentation in medical records can lead to inappropriate medical decisions and higher costs. The purpose of this study was to investigate the deficiencies of the main forms in medical records by the role of documentarians. Methods: This cross-sectional study was conducted in Shafa hospital in Kerman in 2019-2020. The medical records of this hospital were randomly selected. The completion or non-completion of data elements in the main forms of medical records was examined using a valid and reliable checklist. The collected data were analyzed using descriptive statistics in SPSS 24.
No takes yet. Share an insight, caveat, or question.
Salmanizadeh et al. (2020) studied this question.
Synapse has enriched 10 related papers. Consider them for comparative context: