Awareness of Medical Students Regarding Principles of Medical Record Documentation

Abstract

IntroductionAccurate documentation of medical records is one of the important issues during the process of diagnosis and treatment of the disease. It is very important in terms of treatment, legal, educational, financial and research. This study aimed to determine awareness of medical students about principles of medical records documentation.Methods: This descriptive-analytical and cross-sectional study was conducted in 2022-2023 at Zahedan university of medical sciences. The research population included medical students in the preclinical, clinical, and residency levels. The sample size was 260 medical students and the sampling method was quota sampling. The data collection tool was a researcher-made questionnaire. The validity and reliability of questionnaire were confirmed. Descriptive statistics (frequency, percentage, mean, and standard deviation) and analytical tests (T-test and One-way ANOVA) were used to analysis the research data. Results: The average awareness score obtained by the research community was 64.92±14.02 out of 74. The highest and lowest average scores were respectively related to the principles about the time frame of completing the information and the general principles of documenting the medical record. The test of the relationship between the variables of the research showed that only the relationship between the two variables of awareness level and educational level of students was significant.Conclusion: In this study, the level of students' awareness about the principles of documenting medical records was optimal. But by comparing the different results of this research with previous similar studies, it can be said that teaching the principles of documentation over time has had a positive effect on improving the level of students' awareness.

Keywords

• documentation
• medical records
• diagnosis
• procedure