Table 1

The results of evaluation of 300 medical records in terms of availability and completeness at the Alzahra hospital, Tabriz, Iran (23/9/2003 – 22/9/2004)

Sheets

Number of existing sheets

Expected number of sheets

Group A * (%)

Group B † (%)

Group C ‡ (%)

Group D §(%)


Admission and discharge summary

300

300

71

78

88

81

Medical history & physical examination

300

300

67

73

91

100

Physician's order

299

300

54

72

98

100

Progress note

269

300

54

74

99

100

Laboratory report attachment

289

300

56

72

100

100

Radiology report

19

19

57

24

53

95

Electrocardiogram attachment

23

23

65

72

39

15

Consultation request

47

47

64

63

98

56

Vital signs

290

300

59

57

89

100

Composite graphic chart

292

300

57

57

51

N/A¶

Fluid balance chart

85

85

52

57

90

N/A¶

Pre-operation care

123

128

67

71

56

94

Anesthesia record

127

128

97

61

50

99

Operation report

128

128

94

60

69

98

Pathology report

50

50

95

56

51

22

Unit summary

300

300

99

61

87

98


* Percentage of the documentation of demographic information: Unit number, Patient's Name and Family name, Father Name, Date of Birth, Location of Birth, Address and phone number.

† Percentage of the documentation of administrative information: Date of admission, admitting Physician, Ward, Room and Bed number.

‡ Percentage of the documentation of diagnostic and treatment Procedures: Physical examination, Laboratory and Radiological exams, Orders, Medical and Surgical interventions.

§ Percentage of the documentation of identification information of diagnosis and treatment provider: Name and Family name of Physician and Nurse, Signature, Seal, Date and Time.

¶ It is not required to document identification information of care providers on these sheets.

Pourasghar et al. BMC Public Health 2008 8:139   doi:10.1186/1471-2458-8-139

Open Data