This study is a retrospective-descriptive study on the data gathered from Medical Records of hospitalized patients at the Women hospital during a 12 month period from September 23, 2003 through September 22, 2004.
In the Iran medical care system, there are several hospitals, including public hospitals which are run by the Ministry of Health and Medical Education of Iran (MOHME) through universities, private hospitals which are run by private sector physicians and social insurance hospitals which are run by social insurance organization. The university hospitals are dominant in terms of number of the hospitals, number of beds, variety of specialties and services they provide. The university hospitals are public hospitals and available for all people. Patients are usually admitted through the hospitals' clinics or are referred from other health centers and/or private sector physicians.
The patients are required to pay the hospitalization expenses, and if the patients have contract with insurance companies, this companies cover the expenses. Several insurance companies are active in the Iran medical care system.
The women hospital, Alzahra, is the second largest university hospital in Tabriz and is located downtown. This hospital provides medical care for about 20,000 inpatients each year. The PBMR system is the only available documentation system at the hospital. No extra records are kept at the wards. There is an index book at the Medical Records department for recording the identification information of patient, record unit number and the diagnosis after discharge. This book is used to retrieve patient's Medical Records. All information regarding the treatment of patient is written directly by hand on the sheets. Each record is kept at the Medical Records archive at the hospital and is retrieved for use when the patient is admitted for inpatient care or returned to the outpatient clinic for follow up.
A typical Medical Record in the Iran medical care system contains a set of sheets including: admission and discharge summary, medical history and physical examination, physician's order, progress note, laboratory report attachment, radiology report, electrocardiogram attachment, consultation request, vital signs, composite graphic chart, fluid balance chart (24 hours), pre-operation care, anesthesia record, operation report, pathology report and unit summary sheet.
On every sheet there are predefined places for documentation of information regarding identification of patient and physician, clinical exams, medical or surgical interventions and a summary report of Medical Records when the patient is discharged from the hospital. The MOHME has published a set of standard formats for the Medical Records at the University hospitals, which clarify shape, format and content of each sheet of the Medical Records. Based on these standards, the sheets on the Medical Records are categorized in two groups. Each Medical Record comprises a set of fixed and essential sheets. These sheets are mandatory on every record. These are: admission and discharge, medical history and physical examination, physician's order, progress note, laboratory report attachment, vital signs, composite graphic chart and unit summary sheet.
The next group is those sheets that are added based on needs and medical status of the patient. These sheets are: radiology report, electrocardiogram attachment, consultant request, fluid balance (24 hours), pre operation care sheet, anesthesia record, operation report, and pathology report sheet.
Among the 19803 Medical Records of hospitalized patients at the Women hospital between September 23, 2003 and September 22, 2004, 300 Medical Records were randomly selected using an individual unit number which were registered in the index book. All selected records were available immediately.
Since each sheet of the Medical Record contains different informational elements and in order to facilitate the interpretation of the results; we categorized these informational elements into four groups:
A – Demographic information (including unit number, patient's name and family name, father name, date of birth, location of birth, address and phone number)
B – Administrative information – admission information (including date of admission, admitting physician, ward, room and bed number)
C – Diagnostic and treatment procedures (including physical examination, laboratory and radiological tests, medical orders and surgical interventions)
D – Identification information of diagnosis and treatment provider (name and family name of physician and nurse, signature, seal, date and time)
Three aspects of potential problems were studied: availability, completeness and ease of use of Medical Records.
The presence or absence of any required sheet was determined per patient as simple test on availability. Every selected Medical Records was checked if the essential sheets existed; and also when the clinical condition of the patient had mandated to use additional sheets, did those sheets exist in the medical record.
A set of 16 checklists were designed (one for every sheet of medical record) for evaluating the content of records in terms of compatibility with recommended standard format, completeness of medical information, date, time, name and signature of documenter. The checklists were based on the standard Medical Record at the university hospitals in Iran. In these checklists, there was a place for every requested item on every medical record sheet. If the requested information was registered in the sheets correctly, a check mark was consequently placed in the checklist for that specific item. Generally the requested information on each sheet included identification information of patient, physician and ward, the result of medical or surgical interventions and/or laboratory and radiological tests and finally date, time and signature of the care provider.
Since it is expected that the Medical Records hold all clinical information of the patient, the golden standard was to document all requested information elements in the records. Before collecting data and in order to perform a quality control on the checklists, a limited pilot test was carried out on the Medical Records to verify that the checklists covered all essential information.
Ease of use
The ease of use and supplemental information on the possible problems with the existing Medical Records was investigated through interview with staff at the hospital. Ten physicians and ten nurses who were involved in documentation of Medical Records were randomly selected for interviewing. For this purpose, an alphabetically sorted list of all physicians and nurses who were working in the hospital was obtained from the hospital administration. Then ten physicians and ten nurses were selected using simple random sampling method. They were asked if they voluntarily would accept to be interviewed.
The physicians and the nurses were interviewed by using separate semi structured guidelines. Most of the interviews (based on consent of the interviewee) were recorded and then transcribed for analysis. This study was approved by the medical research ethics board in Iran.