Majallah-i Dānishgāh-i ̒Ulūm-i Pizishkī-i Bābul (Dec 2010)
Comparison of Medical Students and Pediatric Residents Practices in Medical Records at Amirkola Children Hospital
Abstract
BACKGROUND AND OBJECTIVE: Writing down medical records of patients in hospital helps physicians to diagnose the patients disease and leads to establish medical care and treatment according to medical records. Incomplete recording of data in patients files leads to complicated problems in medical, legal and economic fields. The goal of this study was to assess the quality of medical records written by pediatric residents, interns and medical students to improve the quality of them. METHODS: In this cross sectional study, the records of patients hospitalized in Amirkola pediatric hospital were studied during 2005-2006. The files were randomly selected and the history, physical examination, progress note, record summaries and final diagnosis were assessed. All items were scored in data collection form and according to the scoring the assessment was categorized in 3 level (good, moderate, weak). Finally, data was analyzed and assessed.FINDINGS: In this study, 730 files were assessed. The quality of writing history by residents, interns and medical students was moderate, moderate and weak, respectively (p=0.000). Quality of writing progress note was weak in three groups (p=0.000). Quality of writing physical examination was moderate in residents, moderate in interns and weak in students (p=0.000). Record summaries was good in residents and interns (p=0.009) and total quality was moderate in residents and interns (p=0.000).CONCLUSION: This findings show that the quality of writing down medical records in residents and interns is moderate. Medical students were weak in all parts of our study. Training medical students in writing medical records seems to be necessary.
