Journal of North Khorasan

Abstract Background and objectives: Medical records contain important and fundamental information about patient care in health centers and include sufficient information for identification of the patient, the diagnostic processing for the health care teams, justification of the treatment and the correct recording of the results. Materials and Methods: The present study is a semi-experimental study done through the completion of nine 3-option check-lists. It is a quantitative study of 9 major sheets of medical records of patients discharged from the university hospitals in Bojnord in 2009. This was done in two rounds, one before training and another 5 months after training. The training consisted two teaching courses titled "Correct procedures in documentation" for physicians and all others recording the documents (ie. nurses and paramedics). 355 records were classified using random sampling. Medical records were chosen from hospitals based on the number of in-patients in each hospital. Data analysis was through SPSS 15 software and using t-test, ANOVA, McNemarra and Tukey tests. Results: The average state of the medical records after training in all the 9 sheets improved significantly (P<0.001) when compared whit before. An exception was the average laboratory test sheets which showed no significant difference. After training the Rate of complete medical records was 75% before training and 79% after training. In the evaluation of the 9 sheets under study, the highest level of completion after training was 93.55% in comparison whit before training (90.45%) the physican ΄s orders report sheet. Conclusion: The study shows a positive effect of training on the rate of medical records completeness. It seems that providing training programes for personnel will improve the quality of constant documentation of medical records.