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Ethics code: IR.SSU.SRH.REC.1401.005
Hamidreza Dehghan 
, Mohammadhosein Soltani , Mahdieh Namayandeh , Fatemeh Majidpoor , Mohammadreza Ahi
, Mohammadhosein Soltani , Mahdieh Namayandeh , Fatemeh Majidpoor , Mohammadreza Ahi
Clinical Research Development Center, Afshar Hospital, Shahid Sadoughi University of Medical Sciences, Yazd, Iran.
Abstract: (10 Views)
Introduction: The transition from paper-based to electronic documentation systems is particularly critical for cardiac patients due to their complex medical history, multiple medications, and need for regular follow-up. This study was conducted to assess the quality of documentation in electronic discharge summaries compared to paper-based records.
Methods: This study was conducted on the files of Afshar Hospital in Yazd between 1400 and 1403. The statistical population included all files of cardiac patients hospitalized in this hospital, and 150 files were selected using a simple random sampling method. The research tool was a researcher-made checklist with 14 items, the validity of which was confirmed through consultation with 8 experts and its reliability was measured in a preliminary study with a Cronbach's alpha coefficient of 0.80. The data were analyzed with SPSS version 23 software and using descriptive statistics.
Results: The electronic system achieved perfect accuracy in recording structured data such as admission codes and hospitalization wards; however, deficiencies in the documentation of information were still observed. The accuracy of patient information recording in the electronic discharge summaries was found to be over 95.8% for demographic data, between 79.2% and 95.8% for clinical data, and 84.2% to 91.7% for therapeutic information. These values remain significantly higher than those for paper-based records.
Conclusion: While the results of this study point to the higher quality of electronic documentation over paper records, they also highlight the imperative for health policymakers to reconsider training, implement ongoing oversight mechanisms, and enhance the technical features of the system.
Methods: This study was conducted on the files of Afshar Hospital in Yazd between 1400 and 1403. The statistical population included all files of cardiac patients hospitalized in this hospital, and 150 files were selected using a simple random sampling method. The research tool was a researcher-made checklist with 14 items, the validity of which was confirmed through consultation with 8 experts and its reliability was measured in a preliminary study with a Cronbach's alpha coefficient of 0.80. The data were analyzed with SPSS version 23 software and using descriptive statistics.
Results: The electronic system achieved perfect accuracy in recording structured data such as admission codes and hospitalization wards; however, deficiencies in the documentation of information were still observed. The accuracy of patient information recording in the electronic discharge summaries was found to be over 95.8% for demographic data, between 79.2% and 95.8% for clinical data, and 84.2% to 91.7% for therapeutic information. These values remain significantly higher than those for paper-based records.
Conclusion: While the results of this study point to the higher quality of electronic documentation over paper records, they also highlight the imperative for health policymakers to reconsider training, implement ongoing oversight mechanisms, and enhance the technical features of the system.
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