|Year : 2015 | Volume
| Issue : 1 | Page : 22-26
Improving the Medical Record Documentation by Quantitative Analysis in a Training Hospital
Sedighe Torki1, Nahid Tavakoli2, Elahe Khorasani3
1 Department of Medical Record, Shahrekord University of Medical Sciences, Shahrekord, Iran
2 Department of Health Management in Disaster, Health Management and Economics Research Center, Isfahan University of Medical Sciences, Kerman, Iran
3 Research Center for Health Services Management, Institute for Futures Studies in Health, Kerman University of Medical Sciences, Kerman; Department of Pharmacoeconomics and Pharmaceutical Administration, School of Pharmacy, Students' Scientific Research Center, Tehran University of Medical Sciences, Tehran, Iran
|Date of Web Publication||3-Jul-2015|
Department of Medical Record, Shahrekord University of Medical Sciences, Shahrekord
Source of Support: This paper is derived from MSc thesis in Isfahan University of Medical Sciences, Isfahan, Iran, Conflict of Interest: None
Introduction: Completed medical records have an important role in hospital evaluation and one thing that usually reduces evaluation score of medical records department and hospital clinical wards is such defects. Therefore, regarding the importance of this matter, this study was done to study recording status of medical records by physicians in a training hospital. Methods: This study was an analytic-descriptive and cross sectional one. The population was inpatients medical record in 2012 and the number of samples was 389 medical records which were chosen by stratified sampling. Finally, after collecting data, they were analyzed by SPSS 13 software both descriptive and inferential statistics and presented in statistical tables. Results: Findings showed that the highest percent is allocated to the presence of progress notes and the lowest percent to recording time of physician first visit. Progress notes was the most incomplete item in wards of NICU, cardiovascular, psychiatric for men, surgery for women, intensive care, emergency, children and psychiatric for women. In wards of CCUII, internal for women, newborns C, and internal for men, lack of physician stamp on summary sheet was the most incomplete item. Conclusions: Progress notes, medical history sheet, and summary sheet were more completed after doing quantitative analysis and using defect eliminating checklist than medical records before November. By attaching defect eliminating form on medical records, we force physicians to complete incomplete records and they understand that completion of these forms will be controlled and these forms have to be completed otherwise records will be referred to them again for completion.
Keywords: Hospital, medical records, physician, quantitative analysis
|How to cite this article:|
Torki S, Tavakoli N, Khorasani E. Improving the Medical Record Documentation by Quantitative Analysis in a Training Hospital. J Earth Environ Health Sci 2015;1:22-6
|How to cite this URL:|
Torki S, Tavakoli N, Khorasani E. Improving the Medical Record Documentation by Quantitative Analysis in a Training Hospital. J Earth Environ Health Sci [serial online] 2015 [cited 2019 May 19];1:22-6. Available from: http://www.ijeehs.org/text.asp?2015/1/1/22/159923
| Introduction|| |
Medical records, manual or mechanical, include information, which describes all aspects of patient's care. Physicians, nurses, and other healthcare providers need medical information for patients' treatment. Medical records act as a link between physicians, patients, and other healthcare providers. Healthcare information causes legal protection for patient, healthcare providers or hospitals when it is necessary or there is a problem. Furthermore, medical records have a big role in supplying financial purposes and determining treatment costs  and supports medical education, healthcare services, and clinical research. 
Above goals will be achieved if healthcare information quality is improved (being complete, legible, and standard). In every healthcare institute, healthcare quality depends on collected data quality and what is often analyzed is data quality, not healthcare quality. 
Furthermore, Huffman (1994), Skurka (1998), and Abdelhak (2001) define quantitative analysis as a process for determining healthcare information completion and World Health Organization (WHO) declare: Medical record has to be complete for assessing documentation quality and subsequently assessing patient's care quality.
Some studies showed that medical records quality reflexes healthcare quality provided by physicians, and an efficient medical record system facilitates medical care assessment and research.  It must be emphasized that information related to healthcare provided for the patient should be true and able to be cited and followed. 
Not only physicians do not spend much time for writing necessary reports in inpatient's record, but also they do not refer to medical record department to complete records, which their defects are specified by defect eliminating form and it has a low priority for them. Therefore, a solution is needed for reducing defects so that medical records can be useful in achieving goals, which medical records are stored for.  Complete and accurate saving and maintaining of medical records is the basic part of patient's treatment management. 
In the age of information and technology, medical records are the most important, the most real and the richest resource of health and medical information because they are based on medical science facts. By scientific optimizing of medical records according to international and national standards and conditions, considering documentation principles and correct structures, applying scientific storing methods, and quick saving, storing and retrieving, there will be a great modification. 
The document maker may not complete data elements intentionally or unintentionally or do not write on his sign and date at the end of documentation procedures because of, he is busy at work. These mistakes in making medical records disturb in medical records users performance. 
Aryaei's study showed that the completion of admission and discharge summary sheet was moderate, and a summary sheet was weak.  Maleky's study showed that the most percentage of completion was related to physician orders sheet and nurses note; composite graphic chart, operation report, and admission sheet were moderate; and summary sheet, medical history sheet, consultation sheet, preoperation care sheet, anesthesia sheet, laboratory reports, electrocardiography, and fluid balance chart were less than moderate and progress notes, pathology and radiology reports were not in none of the hospital records. 
Abbassi's study showed that the most defects were related to recording date and time by document makers, and the least was related to recording data.  Mahmoodian's study showed that the amount of considering documentation standards in emergencies units was only 35.2%.  Nasr-Esfahani's study showed that considering medical records documentation standards in emergency unit was not desired and the most defects was about recording the patient's characteristics on the cover and other forms of the record, signature on physician orders form, and recording date and time by the physician. 
Moran's study showed that residents had completed at least 40% of information related to patients, which were mentioned orally in medical records, for a quarter of them.  Phillips' study showed that among 224 reviewed items, five items (date, physiotherapy title, signature, details form related to patient, patient's condition after the first visit) gained complete score of 100 and 94 items about 81.79%, gained the least score of 50, which seemed reasonable. 
In a study, done in America by the department of defending health care, this department has achieved only 98% of its objectives about documenting timely patients' factures according to defined standards. 
Since some of the medical forms are considered as main forms of patient's record and have special importance such as summary sheet, medical history sheet, progress note; if they are not in medical records or are not completed they can cause incorrect diagnosis during patient's hospitalization (because patient is not visited and cured by only one physician and different physicians may visit the patient and his complete medical record has to be available for physicians) and also after patient's discharge, his medical record will be used for research and legal authorities and so main forms should be completed to show patient's conditions completely. Moreover, completed medical records have an important role in hospital evaluation, and one thing that usually reduces evaluation score of the medical records department and hospital clinical wards is such defects.
Therefore, regarding the importance of this matter, this study was done to study recording status of medical records by physicians in a training hospital. WHO (2003) describes quantitative analysis as a kind of medical record checking for the presence of all healthcare documentation and mention some steps of this process as example: Patient's correct identifying information and all details should be recorded in his medical record completely. Disease history (medical history), physical examinations report and all of the nurse notes, progress notes, and all of the related reports such as: Pathology report, radiology, and so on should exist. When the patient has an operation, anesthesia and operation reports need to be available. All recordings need to have signature and recording date.
The difference between this study and similar studies is that medical records documentation status was reviewed before and after quantitative analysis and using defect eliminating checklist and the effect of this action were measured in the medical records department for eliminating medical records defects.
| Material and Methods|| |
This study was an analytic-descriptive and cross-sectional one. The population was inpatients medical record in 2012 and the number of samples was 389 medical records, which were chosen by stratified sampling, and the number of every unit samples determined based on its medical records and the records were extracted by systematic sampling data collected by the researcher-made checklist including 15 questions. First 9 questions were about presence of medical history, summary sheets and progress notes in medical records, in order to record primary, interim, and final diagnosis on admission sheet, recording time by physician at the first visit on physician orders sheet, recording physician's stamp on medical history and summary sheets, and 3 questions were about completion of progress notes, medical history, and summary sheets that if they were not complete the option of "incomplete" was chosen and if there were at least 1-3 completed items on medical history and summary sheets the option of "somewhat complete" was chosen and for more than 3 items the option of "complete." If progress notes were completed for some days of hospitalization the option of "somewhat complete" was chosen, and if it was completed for all days of hospitalization the option of "complete" was chosen.
The researcher started the work since November in the medical record department regularly and scientifically in order to have an impact on documentation by doing quantitative analysis on records and using defect eliminating form and in this research, documentation was reviewed in two time periods: Before and after November. Finally, after collecting data, they were analyzed by SPSS (IBM Company, New York, USA) 13 software both descriptive and inferential statistics and presented in statistical tables.
| Results|| |
Findings showed that the highest percent (68.4) is allocated to the presence of progress notes and the lowest percent (17.5) to recording time of physician first visit [Table 1].
|Table 1: frequency percentage of presence or absence of reviewed items among studied samples|
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Among selected samples, summary sheet was incomplete in 52.4%, complete in 27.2%, and somewhat complete in 20.3%, medical history sheet was 57.8% complete, 148.3% incomplete, and 23.9% somewhat complete, and progress notes was 72.2% incomplete, 15.4% complete, and 12.3% somewhat complete.
Progress notes was the most incomplete item inward of NICU, cardiovascular, psychiatric for men, surgery for women, intensive care, emergency, children, and psychiatric for women which were 76.9, 71.4, 100, 88.9, 88.6, 833, 69.2, and 100%, respectively. Inward of CCUII, internal for women, newborns C, and internal for men, lack of physician stamp on summary sheet was the most incomplete item with 85.7, 65.4, 60, and 66.7%, respectively.
In infectious diseases ward, unrecorded interim diagnosis with 33.3% and in CCUI, unrecorded primary diagnosis with 57.1% was the most incomplete items.
Findings showed that based on Chi-square test there was a significant relationship between completion of all items of checklist in two time periods before and after November and the most important ones are: Percentage of incomplete summary sheet in first period was 70.3%, which decreased to 13% in second period; this decrease in incomplete progress notes, incomplete medical history sheet, nonrecorded final diagnosis on summary sheet, nonrecorded interim diagnosis on summary sheet, nonrecorded physician stamp on medical history sheet, nonrecorded physician stamp on summary sheet were 78.6-46.3, 25.2-6.5, 23.7-12.2, 32.7-22, 35.2-11.4, and 80.5-26%, respectively.
The presence of checklist items in time periods before and after November is shown in [Table 2]. Moreover, completion of summary sheet was 70.3% incomplete and 12.8% somewhat complete in first time period and 13% incomplete and 37.4% somewhat complete in second time period; medical history sheet was 25.2% incomplete and 24.8% somewhat complete in first time period and 6.5% incomplete and 22.8% somewhat complete in second time period; progress note was 78.6% incomplete and 10.5% somewhat complete in first time period and 46.4% incomplete and 29.2% somewhat complete in second time period. Furthermore, not recording physician stamp on the medical history sheet was 88.8% before November, which decreases to 62.5% after November.
|Table 2: The relationship between presence of medical record sheets and specified time period|
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As it is shown, the presence of progress notes in medical records with 68.4% was the highest percentage of items which were not in inpatients medical records and recording time of physician first visit with 17.5% was the lowest one.
| Discussion|| |
The present study results about progress notes and summary sheet was close to Maleky's (they were completed in <50% of medical records) but about medical history sheet was completed in more than half of medical records in this center and had more favorable conditions than mentioned study. The present study results were similar to Mahmodian's and Nasr-Esfahani's. ,,
Progress notes, medical history sheet, and summary sheet were more completed after doing quantitative analysis and using defect eliminating checklist than medical records before November. In comparison with Maleky study, findings showed progress notes and summary sheet were completed in <50% of records like Maleky's study. However, the medical history sheet was completed in more than 50% of records. However, completion of forms in second time period show that incompletion of medical history and summary sheet decreased from more than 50% to <50% and it means that using defect eliminating form and incomplete referring medical records was useful but in second time period, some medical records were still without main form because of different reasons, which strategies should be considered to complete them.
By attaching defect eliminating form on medical records, we force physicians to complete incomplete records and they understand that completion of these forms will be controlled and these forms have to be completed records otherwise will be referred to them again for completion. This study showed that 52.2% of medical records did not have summary sheet, and the option of "incomplete" was selected and 20.6% of them had somewhat complete summary sheet, and 27.2% of them were complete.
The reason of incomplete summary sheets after referring medical records for completion was the change in internship or residency periods, and the interns do not know patient's disease and so summary sheet remains incomplete. Furthermore, the reason of incomplete medical history sheet in some records after second time period, which means after referring records to the wards, was not recording medical history and patient disease history in medical record such as physician order sheet, so the record was filed incomplete.
In the second time period, completion of the summary sheet in medical records, which were somewhat complete, increased from 12.8% to 37.4% and about complete records it changed from 16.9% to 49.6%. It shows that referring incomplete summary sheets to the ward for completion was effective even in the more accurate completion of the medical record, and physicians were more careful. In spite of using defect eliminating form, some medical records are not completed accurately in the second time period that it shows physicians do not have enough information on completion of these forms.
About recording primary, interim and final diagnosis on admission and discharge summary sheet, this study is close to Aryaei's and Abbassi's study which was moderate and in 70-79% range (9 and 11). This percentage increased after doing quantitative analysis and attaching defect eliminating form.
The remarkable thing is that primary diagnosis is recorded based on patient chief complain and physician first visit at patient admission to medical center, and final diagnosis is the diagnosis of patient discharge time which confirmed for physician after paraclinical and clinical examinations and recording this diagnosis is very important in patient current treatment and follow-up. The primary diagnosis, which is the diagnosis at patient admission time to the hospital and is recorded on the medical history sheet too is not noted on admission sheet by a physician.
One of the reasons for not recording final diagnosis on admission sheet was sending out the patient to more equipped medical center to continue his treatment or discharge without physician order and because physician is not available in such situations, this item remains incomplete. Our study findings were similar to Moran's and Philips' in 94 items but contradict with Philips' first 5 items, which were completed 100%. ,
Interventional study in this research, which was using defect eliminating form for medical records, has a considerable effect on completing records so it is suggested to use the same method for improving medical records documentation in other hospitals; using such management tool and other similar management tools will certainly have an effective role in optimal control of medical records documentation and promoting their quality. Furthermore, innovations in health care have the potential power to improve both quality and efficiency of services. Such innovation is the practice of health care supported by information technology or E-health. 
| Acknowledgments|| |
Hereby we thank research deputy of University of Medical Sciences for supporting this study and also Hospital Medical Records Department personnel.
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[Table 1], [Table 2]