Comparison of Medical Students and Pediatric Residents Practices in Medical Records at Amirkola Children Hospital

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, le...

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Autores principales:	MR Esmaeili, H Abazari, H Mohammadi Kenari
Formato:	article
Lenguaje:	EN FA
Publicado:	Babol University of Medical Sciences 2010
Materias:	medical students residents interns medical records quality Medicine R Medicine (General) R5-920
Acceso en línea:	https://doaj.org/article/ade4371f60ec4e79a0b69fc117cdf990
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id	oai:doaj.org-article:ade4371f60ec4e79a0b69fc117cdf990
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spelling	oai:doaj.org-article:ade4371f60ec4e79a0b69fc117cdf9902021-11-10T09:00:44ZComparison of Medical Students and Pediatric Residents Practices in Medical Records at Amirkola Children Hospital1561-41072251-7170https://doaj.org/article/ade4371f60ec4e79a0b69fc117cdf9902010-12-01T00:00:00Zhttp://jbums.org/article-1-3590-en.htmlhttps://doaj.org/toc/1561-4107https://doaj.org/toc/2251-7170BACKGROUND 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.MR Esmaeili,H Abazari,H Mohammadi KenariBabol University of Medical Sciencesarticlemedical studentsresidentsinternsmedical recordsqualityMedicineRMedicine (General)R5-920ENFAMajallah-i Dānishgāh-i ̒Ulūm-i Pizishkī-i Bābul, Vol 12, Iss 5, Pp 106-111 (2010)
institution	DOAJ
collection	DOAJ
language	EN FA
topic	medical students residents interns medical records quality Medicine R Medicine (General) R5-920
spellingShingle	medical students residents interns medical records quality Medicine R Medicine (General) R5-920 MR Esmaeili, H Abazari, H Mohammadi Kenari Comparison of Medical Students and Pediatric Residents Practices in Medical Records at Amirkola Children Hospital
description	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.
format	article
author	MR Esmaeili, H Abazari, H Mohammadi Kenari
author_facet	MR Esmaeili, H Abazari, H Mohammadi Kenari
author_sort	MR Esmaeili,
title	Comparison of Medical Students and Pediatric Residents Practices in Medical Records at Amirkola Children Hospital
title_short	Comparison of Medical Students and Pediatric Residents Practices in Medical Records at Amirkola Children Hospital
title_full	Comparison of Medical Students and Pediatric Residents Practices in Medical Records at Amirkola Children Hospital
title_fullStr	Comparison of Medical Students and Pediatric Residents Practices in Medical Records at Amirkola Children Hospital
title_full_unstemmed	Comparison of Medical Students and Pediatric Residents Practices in Medical Records at Amirkola Children Hospital
title_sort	comparison of medical students and pediatric residents practices in medical records at amirkola children hospital
publisher	Babol University of Medical Sciences
publishDate	2010
url	https://doaj.org/article/ade4371f60ec4e79a0b69fc117cdf990
work_keys_str_mv	AT mresmaeili comparisonofmedicalstudentsandpediatricresidentspracticesinmedicalrecordsatamirkolachildrenhospital AT habazari comparisonofmedicalstudentsandpediatricresidentspracticesinmedicalrecordsatamirkolachildrenhospital AT hmohammadikenari comparisonofmedicalstudentsandpediatricresidentspracticesinmedicalrecordsatamirkolachildrenhospital
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Comparison of Medical Students and Pediatric Residents Practices in Medical Records at Amirkola Children Hospital

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