Quality of Care by Good Medical Records Documentation in Educational Hospitals

Background: Documentation in the medical record facilitates the diagnosis and treatment of patients. Considering the necessity of documentation the data of diabetic patients and its effect on the treatment, a study designed and conducted in order to determine the condition of documentation of medical records. Methods: This is a retrospective cross sectional descriptive study and the subjects entering the study were all of the diabetic patients referring to the Imam Khomeini and Bo Ali educational hospitals in Sari City, Iran in 2007-2008. The patient characteristics calculated on a subset of 270 diabetic diseases: 5.6% type I Insulin-dependent diabetes mellitus and 5.2% Type II diabetics, 18.5% was Gestational diabetes. 270 patient records were selected. Then, based on documented data in the admit ion record, summary sheet, history, paramedical tests and checklist were completed. The record data under study included demographic features, clinical history, laboratory examinations, complications and problems, and treatment used. The collected data were analyzed statistically using SPSS software version 17. Results: The obtained data indicated that 76.95% of the demographic features, 24.3% of clinical history, 6.8% of physical examinations and 30.4% of the examinations documented. Conclusion: Findings of this study, showed that documentation of process of the patient records in the diabetic patients by the physicians who are the main health care team along with medical students, interns and residents.