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A quantitative study on completeness rate of documentation in psychiatric medical records.
Ebnehoseini, Zahra; Khorasani, Hediye; Moharari, Fatemeh; Ebrahimi, Ali Reza; Boroujerdi, Masoumeh; Jamei, Fatemeh; Mehri, Mohammad Reza; Tabesh, Hamed.
Afiliación
  • Ebnehoseini Z; Department of Medical Informatics, Psychiatry and Behavioral Sciences Research Center, Mashhad University of Medical Sciences, Mashhad, Iran.
  • Khorasani H; Department of Medical Informatics, Mashhad University of Medical Sciences, Mashhad, Iran.
  • Moharari F; Department of Psychiatry, Psychiatry and Behavioral Sciences Research Center, Mashhad University of Medical Sciences, Mashhad, Iran.
  • Ebrahimi AR; Department of Psychiatry, Psychiatry and Behavioral Sciences Research Center, Mashhad University of Medical Sciences, Mashhad, Iran.
  • Boroujerdi M; Department of Health Information Technology, Psychiatry and Behavioral Sciences Research Center, Mashhad University of Medical Sciences, Mashhad, Iran.
  • Jamei F; Department of Nursing, Psychiatry and Behavioral Sciences Research Center, Mashhad University of Medical Sciences, Mashhad, Iran.
  • Mehri MR; Traditional Medicine Specialist, Mashhad University of Medical Sciences, Mashhad, Iran.
  • Tabesh H; Department of Medical Informatics, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran.
Indian J Psychiatry ; 64(2): 185-191, 2022.
Article en En | MEDLINE | ID: mdl-35494327
Background: Mental disorders are one of the leading causes of illness and disability worldwide. According to the World Health Organization (WHO), one in four people in the world will be affected by mental or neurological disorders during their lifetime. Regular evaluation of mental health outcomes plays an important role in making decisions about timely treatment of the patient. Studies show that a medical record does not provide enough information about the diagnosis, current symptoms, psychiatric medications, and side effects of current medications and treatments for ongoing health care. In this study, the completeness of paper-based psychiatric records was investigated. Aim: The current study aimed to explore the completeness rate of paper-based psychiatric medical records (PMRs) and to investigate the factors effective on documentation status. Setting: The study was conducted in Ebnesina and Dr. Hejazi Psychiatric Hospital and Education Center. The case hospital is a psychiatric teaching hospital, which has 900 beds. Materials and Methods: The completeness rate of PMRs was determined using descriptive statistics. Fleiss' Kappa agreement and effective factors on PMRs' documentation status were assessed. Results: In total, 83.65% (n = 312) of the PMRs had at least one documentation defect. A significantly higher level of documentation completeness rate between different psychiatric wards was observed. Conclusion: Based on our results, it is suggested to conduct regular evaluation and provide feedback to the health-care providers, and conduct training courses.
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Texto completo: 1 Colección: 01-internacional Base de datos: MEDLINE Tipo de estudio: Prognostic_studies Idioma: En Revista: Indian J Psychiatry Año: 2022 Tipo del documento: Article País de afiliación: Irán Pais de publicación: India
Texto completo
Añadir a Mi BVS
Imprimir
XML
PubMed Links
Buscar en Google

Texto completo: 1 Colección: 01-internacional Base de datos: MEDLINE Tipo de estudio: Prognostic_studies Idioma: En Revista: Indian J Psychiatry Año: 2022 Tipo del documento: Article País de afiliación: Irán Pais de publicación: India