title: Documentation of Medical Records in Hospitals of Mazandaran University of Medical Sciences in 2014: a Quantitative Study.
abstract: BACKGROUND
  Documentation of patient care in medical record formats is always emphasized. These documents are used as a means to go on treating the patients, staff in their own defense, assessment, care, any legal proceedings and medical science education. Therefore, in this study, each of the data elements available in patients' records are important and filling them indicates the importance put by the documenting teams, so it has been dealt with the documentation the patient records in the hospitals of Mazandaran province.
  
  
  METHODS
  This cross-sectional study aimed to review medical records in 16 hospitals of Mazandaran University of Medical Sciences (MazUMS). In order to collection data, a check list was prepared based on the data elements including four forms of the admission, summary, patients' medical history and progress note. The data recording was defined as "Yes" with the value of 1, lack of recording was defined as "No" with the value of 2, and "Not applied" with the value of 0 for the cases in which the mentioned variable medical records are not applied.
  
  
  RESULTS
  The overall evaluation of the documentation was considered as 95-100% equal to "good", 75-94% equal to "average" and below -75% equal to "poor". Using the stratified random sample volume formula, 381 cases were reviewed. The data were analyzed by the SPSS version 19 and descriptive statistics.
  
  
  RESULTS
  The results showed that %62 of registration and all the four forms were in the "poor" category. There was no big difference in average registration among the hospitals. Among the educational groups Gynecology and Infectious were equal and had the highest average of documentation of %68. In the data categories, the highest documentation average belonged to the verification, %91.
  
  
  CONCLUSIONS
  According to the overall assessment in which the rate of documentation was in the category "week", we should make much more efforts to reach better conditions. Even if a data element is recognized meaningless, unnecessary and repetitive by the in charge of documentation, it should not be neglected and skipped. In order to solve the problems of these types, it is suggested to discuss the medical records forms and elements that seem unnecessary in the related committees.
authors.affiliation: Health Information Management Office, Mazandaran University of Medical Sciences, Sari, Mazandaran, Iran.
authors.forename: Benyamin Mohseni
authors.initials: BM
authors.lastname: Saravi
authors.affiliation: Health Information Management Office, Mazandaran University of Medical Sciences, Sari, Mazandaran, Iran.
authors.forename: Zolaykha
authors.initials: Z
authors.lastname: Asgari
authors.affiliation: Medical Records and Health Information Technology Department, School of Allied Medical Sciences, Mazandaran University of Medical Sciences, Sari, Mazandaran, Iran.
authors.forename: Hasan
authors.initials: H
authors.lastname: Siamian
authors.affiliation: Statistics and Mathematics Department, Islamic Azad University, Sari Branch, Sari, Mazandaran, Iran.
authors.forename: Ebrahim Bagherian
authors.initials: EB
authors.lastname: Farahabadi
authors.affiliation: Educational Development Center (EDC), Mazandaran University of Medical Sciences, Sari, Iran.
authors.forename: Alimorad Heidari
authors.initials: AH
authors.lastname: Gorji
authors.affiliation: Social Medicine Department, Zanjan University of Medical Sciences, Zanjan, Iran.
authors.forename: Nima
authors.initials: N
authors.lastname: Motamed
authors.affiliation: Health Information Management Office, Mazandaran University of Medical Sciences, Sari, Mazandaran, Iran.
authors.forename: Mohammad
authors.initials: M
authors.lastname: Fallahkharyeki
authors.affiliation: Health Information Management Office, Mazandaran University of Medical Sciences, Sari, Mazandaran, Iran.
authors.forename: Ramin
authors.initials: R
authors.lastname: Mohammadi
keywords: analysis- medical sheets; documentation; medical records