title: THE QUANTITATIVE STUDY OF THE FACULTY MEMBERS PERFORMANCE IN DOCUMENTATION OF THE MEDICAL RECORDS IN TEACHING HOSPITALS OF MAZANDARAN UNIVERSITY OF MEDICAL SCIENCES.
abstract: BACKGROUND
  Documentation of patients' medical records has been always emphasized because medical records are as a means to be applied by patients, all medical staff, quality evaluations of health care, lawsuits, medical education and, etc. Regarding to this, each of the data elements available in the sheets of medical records has their own values. The rate of completion indicates the importance of the medical recorders for faculty member. So in this article the researcher evaluates the completion of medical records in the teaching hospitals of Mazandaran University of Medical Sciences.
  
  
  METHODS
  This cross- sectional study has been conducted to review the patients' medical cases in five teaching university hospitals. To collect data, a check list was mode based on data element arrangement in four main sheets of admission and discharge, summery, patients' history and clinical examination and progress note sheets. Recorded data were defined as "Yes" with the value 1, not recorded data were defined as "No" with the value 2, and not used data were defined for cases in which the mentioned variable had no use with the value Zero. The overall evaluation of the rate of documentation was considered as %95 -100 equal to "good", 75-94% equal to average and under 75% was considered as "poor". Using the sample volume formula, 281 cases were randomly stratified reviewed. The data were analyzed by the software SPSS version 19 and descriptive statistical scales.
  
  
  RESULTS
  The results have shown that the overall documentation rate in all the four sheets was 62% and in a poor level. There was no big difference in the average documentation among the hospital. Among the educational group, the gynecology and infection groups are equal to each other and had the highest record average (68%). Within the all groups, the highest rate has belonged to the documentation of signatures (91%).
  
  
  CONCLUSIONS
  Regarding to the overall assessment that documentation rate was in a poor level, more attempt should be made to achieve a better condition. Even if a data element of the sheets seems meaningless, unnecessary and duplicated, it should not be ignored and skipped. In order to solve such problems, it is suggested that medical records sheets and the elements that seem unnecessary, should be reviewed in relevant committees.
authors.affiliation: Health Sciences Research Center, Health Information Management Office, Mazandaran University of Medical Sciences, Sari, Mazandaran, Iran.
authors.forename: Zolaykha
authors.initials: Z
authors.lastname: Asghari
authors.affiliation: Nuclear Medicine Department. Mazandaran University of Medical Sciences, Sari, Iran.
authors.forename: Alireza
authors.initials: A
authors.lastname: Mardanshahi
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: Library and Information Sciences, School of Allied Medical Sciences, Sari, Mazandaran, Iran.
authors.forename: Hasan
authors.initials: H
authors.lastname: Siamian
authors.affiliation: Educational Development Center (EDC), Mazandaran University of Medical Sciences, Sari, Iran.
authors.forename: Ali Morad Heidari
authors.initials: AM
authors.lastname: Gorji
authors.affiliation: Health Information Management Office, Mazandaran University of Medical Sciences, Sari, Mazandaran.
authors.forename: Benyamin Mohseni
authors.initials: BM
authors.lastname: Saravi
authors.affiliation: Health Information Management Office, Mazandaran University of Medical Sciences, Sari, Mazandaran.
authors.forename: Esmaeil
authors.initials: E
authors.lastname: Rezazadeh
authors.affiliation: Mazandaran University of Medical Sciences, Sari, Mazandaran, Iran.
authors.forename: Seyyed Payam
authors.initials: SP
authors.lastname: Paymard
keywords: Assessment; Documentation; Faculty; medical forms