The Effect of Medical Recording Training on Quantity and Quality of Recording in Gynecology Residents of Tabriz University of Medical Sciences

Introduction: Medical records contain valuable information about a patient's medical history and treatment. Patient safety is one of the most important dimensions of health care quality assurance and performance improvement. Completing the process of documentation is necessary to continue patient care and continuous quality improvement of basic services. The aim of the present study was to evaluate the effect of medical recording education on the quantity and quality of recording in gynecology residents of Tabriz University of Medical Sciences.

Methods: This study is a quasi-experimental study and was conducted at Al-Zahra Teaching Hospital, Tabriz, Iran, in 2016. Thirty-two second through fourth year gynecologic residents of Tabriz University of Medical Sciences who were willing to participate in the study were included by census sampling and participated in training workshop. Three evaluators reviewed the residents’ records before and after training course by a checklist. Statistical analyses were performed using SPSS 13 software. P-values less than 0.05 were considered statistically significant.

Results: The results showed that before the intervention, there were significant differences in the quantity of information status among the evaluators and no significant difference was observed in the recording of qualitative status. After the workshop, among the 3 evaluators, there were also significant differences in the quantity of data recording status; however, no significant change was observed in recording of qualitative status.

Conclusion: The study findings revealed that a sectional training course of correct and standardized medical records has no effect on reforming the process of recording.

Design and evaluation of electronic briefs of neonatal intensive care unit in Taleghani hospital, Tabriz, Iran

More than 9 million neonatal deaths are reported through out the world each year happening in the early weeks of life most of which relate to developing countries. Thus it is very important to present a better way to keep the infants healthy which could be possible by accessing accurate information at any time required during hospitalization of infants. Therefore the required data should be collected, stored and analyzed before which is best possible by using computer. The main objective of this research is enabling researchers and clinicians quick access to the data of the babies admitted in NICU. This study involves the stage of developing a system design and its implementation following the evaluation of the electronic records which is done in a query form. By defining the neccessary terminology and designing a data model, the database and user interface are developed by using a programing language and data base tools. Finally, the system has been evaluated by user satisfaction showing to be about 85% As a result we suggest the hospitals take serious in buying the suitable technology for the NICU ward along with teaching the staffs how to work with it.