Impact of an Educational Intervention on Medical Records Documentation Publisher



Vahedi HS¹ ; Mirfakhrai M² ; Vahidi E¹ ; Saeedi M¹ Show Affiliations
Source: World Journal of Emergency Medicine Published:2018

Abstract

BACKGROUND: Inaccurate and incomplete documentation can lead to poor treatment and medicolegal consequences. Studies indicate that teaching programs in this fi eld can improve the documentation of medical records. The study aimed to evaluate the effect of an educational workshop on medical record documentation by emergency medicine residents in the emergency department. METHODS: An interventional study was performed on 30 residents in their fi rst year of training emergency medicine (PGY1), in three tertiary referral hospitals of Tehran University of Medical Sciences. The essential information that should be documented in a medical record was taught in a 3-day-workshop. The medical records completed by these residents before the training workshop were randomly selected and scored (300 records), as was a random selection of the records they completed one (300 records) and six months (300 records) after the workshop. RESULTS: Documentation of the majority of the essential items of information was improved significantly after the workshop. In particular documentation of the patients' date and time of admission, past medical and social history. Documentation of patient identity, requests for consultations by other specialties, fi rst and fi nal diagnoses were 100% complete and accurate up to 6 months of the workshop. CONCLUSION: This study confirms that an educational workshop improves medical record documentation by physicians in training. © 2017 World Journal of Emergency Medicine.