Effect of Attaching Standard Medical Recording Guidelines to the Patient File on Quality of Medical Students’ Skills

Abstract

Introduction: Currently, medical staff of hospitals use a number of recorded files in the treatment process of patients, but we have noticed that there are insufficiencies and gaps in data of the medical recordings, some of which may be the reason behind serious problems related to treating patients. Other studies have shown some weaknesses in the medical recording systems in our country so we studied effect of attaching a standard recording guidelines sheet to patients’files as a reference for the recorder. Methods: In this study, 50 externs and 40 interns were enrolled. They were responsible for 60 patients in the general internal medicine ward of Sina hospital, University of Medical Sciences, Tabriz, Iran. This study was done during 6 months in the Sina hospital (January 2010-August 2010). Standard medical recording guidelines were attached to the patients’ files. The externs studied off note writing, and the interns studied consultation, off note and orders writing in the first day of patient hospitalization. The quality of their medical writing was assessed before and after attaching guidelines. The students were not aware of the evaluation of their work. If the writing met less than 70% of the standard format, it was not accepted. Result: The consultation sheet of the interns showed significant differences before and after the guidelines’ attachment in problem list writing (p= 0.005). Other studied aspects did not have any significant difference. Affixed guidelines, therefore, could solve the problem of list recording, but did not alter other items. Conclusion: This study showed that the interns had many problems in medical recording which would not be solved with attaching a standard medical recording checklist, and we must choose other methods to correct those errors.

Keywords

• Medical recording
• Guidelines
• Medical students