Evaluating Documentation for Coding of Poisoning Medical Records in Imam Reza Hospital, Mashhad, Iran

Abstract

Introduction: Medical records can be defined as a document of the patients' treatment process. Complete and accurate information recording in the medical records of poisoned patients can play an important role in their complete clinical coding. This study aims to determine the amount of registered information required for clinical coding in the medical records of poisoned patients admitted to Imam Reza Hospital in Mashhad, Iran. Methods: This descriptive cross-sectional study was conducted in 2019. 387 records were selected and reviewed by simple random sampling from all medical records of patients admitted to the poisoning ward of Imam Reza Hospital of Mashhad University of Medical Sciences. The instrument was a valid and reliable checklist. Data analysis was conducted using descriptive statistics. Results: The type of poisoning was registered in 387 (100%) medical records and in only 20 (5.2%) medical records the poisoning substance was an unknown drug. In 183 (47.3%) medical records, an external cause was registered for the poisoning, with 19 (4.9%) and 1 (0.3%) medical records including the individual's place of exposure and activity during exposure, respectively. Conclusion: The findings of this study can be used to plan and compile the necessary guidelines for the proper accurate documentation of medical records and the possibility of high quality clinical coding.

Keywords

• poisoning
• medical records
• clinical coding
• documentation
• international classification of diseases