Aim: Due to the importance of continuous evaluation of medical records to meet the stakeholders' needs and the lack of a comprehensive and unique tool in this field, this comparative study was conducted with the aim of investigating the quantitative evaluation indicators of inpatient medical records and validation of the proposed tool.
Methods: This cross-sectional study was performed in a descriptive-comparative method in 2019. Quantitative evaluation checklists for medical records were collected by reviewing articles and guidelines. Theas data were collected by using internet search on Google and Google Scholar and scientific databases such as Scopus, Science Direct, PubMed, SID, and Iran DOC. Keywords related to quantitative evaluation of medical records were used to search. The primary tool was developed according to sources frequency. The primary tool was surveyed by Delphi method in a round of 10 academic members of the Health Information Technology faculty A focus-group meeting was held to examine the feasibility of the proposed tools. The data were analyzed by using Excell software 2016.
Results: A total of 51 hospital checklists, 44 articles and 10 related national and international guidelines were reviewed. Based on the frequency and importance of the indicators studied in these sources, a proposed tool for quantitative evaluation of the file was developed at four levels. Finally, after dolphin agreement and focus-group meeting, one tool with 20 main indicators was presented at four levels: red level (with critical errors), orange (major errors), yellow (minor errors), and green (no such errors) were presented.
Conclusion: The tool presented in this study will be practical because of its prioritization feature between indicators and error classification for evaluating, comparing, and following the improvement of inpatients' medical records in different wards in terms of documentation priorities.
Type of Study:
Research |
Subject:
Special Received: 2020/03/11 | Accepted: 2020/05/26 | Published: 2020/06/19