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Journal of Caring Sciences
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Article History
Submitted: 23 Jul 2016
Revised: 05 Jan 2017
Accepted: 22 Jan 2017
First published online: 31 Aug 2017

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J Caring Sci. 2017;6(3):281-292 doi: 10.15171/jcs.2017.027

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

Original Research

Manizheh Sayyah-Melli 1 * , Malahat Nikravan Mofrad 2, Abolghasem Amini 3, Zakieh Piri 4, Morteza Ghojazadeh 5, Vahideh Rahmani 6

1 Departement of Obstetrics and Gynecology, Shahid Beheshti University of Medical Sciences, School of Medical Education, Tehran, Iran
2 Departement of Nursing, School of Nursing & Midwifery, School of Medical Education, Shahid Beheshti University of Medical Sciences, Tehran, Iran
3 Department and Center for Educational Research and Development (EDC), Tabriz University of Medical Science, Tabriz, Iran
4 Department of Medical Records, Tabriz University of Medical Sciences, Tabriz, Iran
5 Research Center of Evidence-Based Medicine, Tabriz University of Medical Sciences, Tabriz, Iran
6 Women's Reproductive Health Research Center, Tabriz University of Medical Sciences, Tabriz, Iran



Abstract
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.





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Articles by Sayyah-Melli M
Articles by Nikravan Mofrad M
Articles by Amini A
Articles by Piri Z
Articles by Ghojazadeh M
Articles by Rahmani V

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Articles by Sayyah-Melli M
Articles by Nikravan Mofrad M
Articles by Amini A
Articles by Piri Z
Articles by Ghojazadeh M
Articles by Rahmani V



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