What they fill in today, may not be useful tomorrow: Lessons learned from studying Medical Records at the Women hospital in Tabriz, Iran

Table 1 The results of evaluation of 300 medical records in terms of availability and completeness at the Alzahra hospital, Tabriz, Iran (23/9/2003 – 22/9/2004)

Sheets	Number of existing sheets	Expected number of sheets	Group A * (%)	Group B † (%)	Group C ‡ (%)	Group D §(%)
Admission and discharge summary	300	300	71	78	88	81
Medical history & physical examination	300	300	67	73	91	100
Physician's order	299	300	54	72	98	100
Progress note	269	300	54	74	99	100
Laboratory report attachment	289	300	56	72	100	100
Radiology report	19	19	57	24	53	95
Electrocardiogram attachment	23	23	65	72	39	15
Consultation request	47	47	64	63	98	56
Vital signs	290	300	59	57	89	100
Composite graphic chart	292	300	57	57	51	N/A¶
Fluid balance chart	85	85	52	57	90	N/A¶
Pre-operation care	123	128	67	71	56	94
Anesthesia record	127	128	97	61	50	99
Operation report	128	128	94	60	69	98
Pathology report	50	50	95	56	51	22
Unit summary	300	300	99	61	87	98

* Percentage of the documentation of demographic information: Unit number, Patient's Name and Family name, Father Name, Date of Birth, Location of Birth, Address and phone number.
† Percentage of the documentation of administrative information: Date of admission, admitting Physician, Ward, Room and Bed number.
‡ Percentage of the documentation of diagnostic and treatment Procedures: Physical examination, Laboratory and Radiological exams, Orders, Medical and Surgical interventions.
§ Percentage of the documentation of identification information of diagnosis and treatment provider: Name and Family name of Physician and Nurse, Signature, Seal, Date and Time.
¶ It is not required to document identification information of care providers on these sheets.

ISSN: 1471-2458