scholarly journals The influence of knowledge and perceptions of doctors on the quality of medical records

2021 ◽  
Vol 10 (2) ◽  
Author(s):  
Nining Dwi Suti Ismawati ◽  
Stefanus Supriyanto ◽  
Setya Haksama ◽  
Cholicul Hadi

Background: Medical record reflects the quality of health services provided, which is influenced by existing resources, such as the doctors in charge. This study aims to determine whether doctors' knowledge and perceptions affect the quality of the medical record.Design and Methods: This is a quantitative and cross-sectional study carried out at Dr. Soetomo's general and academic hospital Surabaya, Indonesia, in September and October 2020. Data were purposively obtained from a total of 45 doctors working at the hospital's inpatient service surgery ward using the questionnaire and checklist medical record quality. Furthermore, ethical clearance and doctors’ informed consent were obtained, with the data statistically processed and analyzed by multiple linear regressions.Results: The results and conclusion showed that doctors' knowledge and perceptions of the quality of medical records were influence to medical record quality (p<0.05).Conclusions: Hospital management needs to regularly increase doctors' knowledge and perceptions by socializing and monitoring medical records.

2021 ◽  
Author(s):  
MHD Bahaa Aldin Alhaffar ◽  
Khattab Mustafa ◽  
Samira Alsabbagh ◽  
Ola Alhaffar ◽  
Ameer Kakaje

Abstract Background:Since 2011, Syria has been facing a conflict that impacted all aspects of life. Haematological malignancies are mainly treated with chemotherapy which can further harm oral health. This study evaluates oral health of children with haematological malignancies and on chemotherapy in Syria.Methods: This is a cross-sectional study of (40) patients from the major paediatric hospital in Damascus. Decayed, Missing, Filled Teeth (DMFT) and Oral Assessment Guide (OAG) indices were used to evaluate oral health. Data about cancer was collected from medical records. Results: Patients aged between 3-14 years. Three types of paediatric cancer were included; acute lymphoblastic leukaemia (ALL) 52.2%, Hodgkin’s Lymphoma (HL) 27.5%, and Burkitt Lymphoma (BL) 20%. Average DMFT was (6.7 ± 3.2) and average OAG index was (10.8 ± 1.7). DMFT was significantly correlated with OAG (r=0.021). In patients undergoing chemotherapy, better DMFT and OAG indices were reported in males who had cancer for shorter periods, had higher frequency of toothbrushing, or/and were helped while toothbrushing. However, age and cancer type did not significantly affect DMFT and OAG.Conclusion: Children undergoing chemotherapy in Syria had worse oral health and pain compared to other children from the same age in similar studies. More attention should be given to these patients in order to improve their overall health and their quality of life especially during the ongoing conflict.


2020 ◽  
Vol 9 (1) ◽  
pp. 59-63
Author(s):  
S Aryal ◽  
A Jha

   Introduction: The quality of life of people with epilepsy is hampered both by the nature of the disorder and its associated effects. This study was carried out to assess the quality of life in patients with epilepsy and determine the influence of various factors in quality of life in these patients. Material And Method: A cross sectional descriptive study was conducted in Mental Hospital, Lagankhel enrolling clinically diagnosed patients with epilepsy aged more than 18 years and on antiepileptic drugs for at least 6 months. Patients diagnosed with epilepsy but having mental retardation, overt cognitive impairment, psychiatric disorders or other co-morbid chronic systemic or neurological illnesses which could affect QOL were excluded from the study by detailed history, clinical examinations, previous medical records and relevant investigations. Results: Statistically significant differences in the quality of life scores were seen in terms of educational and marital status, and frequency of seizures within the last 6 months before evaluation. Statistically insignificant positive correlation was observed between the age of onset of seizures and the QOL scores. Similarly, statistically insignificant negative correlation observed between the number of drugs used and the QOL scores. Conclusion: Duration of epilepsy had a consistent negative effects on QOL. Evaluation of quality of life in epilepsy relatively measures the outcome for treatment for epilepsy.


2020 ◽  
Vol 26 (2) ◽  
pp. 1-13
Author(s):  
Ekhlas Abu Sharikh ◽  
Rifat Shannak ◽  
Taghrid Suifan ◽  
Omar Ayaad

Background/aims Electronic medical records are the most common E-health application and they are starting to be implemented worldwide. In Jordan, the introduction of electronic medical records helps to improve quality and reduce service costs. This article aimed to examine how the implementation of electronic medical records impacted health service quality in Jordan. Methods A cross-sectional study was conducted in Jordanian hospitals that used electronic medical records. The data were collected using a self-administered questionnaire, which 582 healthcare professionals returned. The Statistical Package for Social Sciences was used to perform descriptive and statistical analyses. Results The results showed that there was a statistically significant impact when using electronic medical records. These findings were divided into two categories: function (practice management, communication, documentation or data entry, and medication management) and on the quality of services (reliability, responsiveness, assurance, and empathy). Conclusions The research indicated that using electronic medical records improved the quality of health services.


2014 ◽  
Vol 48 (4) ◽  
pp. 602-609 ◽  
Author(s):  
Isabella Schroeder Abreu ◽  
Maria Fernanda Cabral Kourrouski ◽  
Danielle Maria de Souza Serio dos Santos ◽  
Monika Bullinger ◽  
Lucila Castanheira Nascimento ◽  
...  


The aim of this study was to estimate the prevalence and factors associated with the occurrence of incidents related to medication, registered in the medical records of patients admitted to a Surgical Clinic, in 2010. This is a cross-sectional study, conducted at a university hospital, with a sample of 735 hospitalizations. Was performed the categorization of types of incidents, multivariate analysis of regression logistic and calculated the prevalence. The prevalence of drug-related incidents was estimated at 48.0% and were identified, as factors related to the occurrence of these incidents: length of hospitalization more than four days, prescribed three or more medications per day and realization of surgery intervention. It is expected to have contributed for the professionals and area managers can identify risky situations and rethink their actions.



BMJ Open ◽  
2019 ◽  
Vol 9 (12) ◽  
pp. e030944
Author(s):  
Kelienny de Meneses Sousa ◽  
Isac Davidson Santiago Fernandes Pimenta ◽  
María Fernández Elorriaga ◽  
Pedro Jesus Saturno-Hernandez ◽  
Tatyana Maria Silva de Souza Rosendo ◽  
...  

ObjectiveTo evaluate the quality of delivery care in maternity wards in Brazil and Mexico based on good practices (GP) and adverse events (AE), in order to identify priorities for improvement.DesignA multicentre cross-sectional study with data collection from medical records between 2015 and 2016 to compare indicators of maternal and neonatal GP and EA based on the Safe Childbirth Checklist and standardised obstetric quality indicators. Two Brazilian and five Mexican maternity wards participated in the study. Descriptive statistics and χ2tests were performed to assess performance and significant differences between the hospitals investigated.SamplingWe analysed 720 births in Brazil and 2707 in Mexico, which were selected using a systematic random sampling of 30 medical records every fortnight for 12 2-week periods in Brazil and 18 2-week periods in Mexico. We included women and their newborns, excluding those with congenital malformations.ResultsThe Mexican hospitals showed greater adherence to GP (58.2%) and a lower incidence of AE (12.9%) than the participating institutions in Brazil (26.8% compliance with GP and 16.0% AE). In spite of these differences, the relative importance of particular quality problems and type of AE are similar in both countries. Tertiary hospitals, caring for women at higher risk, have significantly (p<0.001) higher rates of AE (27.2% in Brazil and 29.6% in Mexico) than institutions attending women at lower risk, where the frequency of AE ranges from 4.7% to 11.2%. Differences were significant (p<0.001) for most indicators of GP and AE.ConclusionData from outcome and process measures revealed similar types of failures in the quality of childbirth care in both countries and indicate the need of rationalising the use of antibiotics for the mother and episiotomy, encouraging greater adherence to partograph and to the use of magnesium sulfate for the treatment of severe preeclampsia/eclampsia.


2021 ◽  
Vol 2 (2) ◽  
pp. 62-73
Author(s):  
Besse Lizanty Triananda ◽  
Indahwaty Sidin ◽  
Masni Masni ◽  
Syahrir A. Pasinringi ◽  
Fridawaty Rivai ◽  
...  

Medical record is a subsystem of the hospital information system as a whole which has a very important role in improving the quality and service in hospitals. This study aims to analyze the factors related to the completeness of filling and the timeliness of returning medical record files for inpatients at Tarakan Hospital. This type of research is a quantitative study using an observational study with a cross sectional study design. Sampling used total sampling so that the sample in this study were doctors at the Inpatient Installation of Tarakan Hospital, totaling 38 respondents. The results showed that there was a relationship between individual characteristics, organizational characteristics, job characteristics and SOPs with the completeness of filling out medical record files and the timeliness of returning medical record files at Tarakan Hospital. Therefore, it is hoped that the hospital management will continue to improve monitoring and evaluation of the importance of maintaining the quality of medical records, then immediately switch to electronic medical records in order to solve problems that exist in the medical record unit, so that performance improvements and service quality in hospitals can be realized. Tarakan which has an impact on increasing patient satisfaction and loyalty


Author(s):  
Mahlagha Dehghan ◽  
Roghayeh Mehdipour-Rabori ◽  
Masoud Rayani ◽  
Mohammad Ali Zakeri ◽  
Mina Mobasher ◽  
...  

Patients’ rights are among the most important criteria for evaluating the quality of health services. The current study aimed to determine the importance and observance of the patient's bill of rights. This cross-sectional study was done in Kerman, Iran. The research samples were 217 patients and 204 personnel. The data collection tool was a researcher-made questionnaire in the scope of the patient's bill of rights, and data were analyzed by SPSS 15. The results showed a significant difference between patients and the personnel on the subject of the patient's bill of rights and most of its dimensions (P < 0.01). However, no significant difference was found between their views on the observance of the patient's bill of rights and its dimensions. Also, 35.9% of patients as well as 25% of personnel considered the observance of patients’ rights unfavorable. The participants were aware of the importance of the patient's bill of rights. It is necessary, however, to codify and approve the laws related to the rights of patients.


BMJ ◽  
2007 ◽  
Vol 335 (7629) ◽  
pp. 1085 ◽  
Author(s):  
Ira B Wilson ◽  
Bruce E Landon ◽  
Peter V Marsden ◽  
Lisa R Hirschhorn ◽  
Keith McInnes ◽  
...  

Objective To determine whether a selected set of indicators can represent a single overall quality construct. Design Cross sectional study of data abstracted during an evaluation of an initiative to improve quality of care for people with HIV. Setting 69 sites in 30 states. Data sources Medical records of 9020 patients. Main outcome measures Adjusted performance rates at site level for eight measures of quality of care specific to HIV and a site level summary performance score (the number of measures for which the site was in the top quarter of the distribution). Results Of 28 site level correlations between measures, two were greater than 0.40, two were between 0.30 and 0.39, four were between 0.20 and 0.29, and the 20 remaining were all less than 0.20. One site was in the top quarter for seven measures, but no sites were in the top quarter for six or eight of the measures. Across the eight quality measures, sites were in the top quarter no more often than predicted by a chance (binomial) distribution. Conclusions The quality suggested by one measured indicator cannot necessarily be generalised to unmeasured indicators, even if this might be expected for clinical or other reasons.


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