Qom University of Medical Sciences Journal

Backgrounds and Objectives: High-quality health care depends on comprehensive information of medical record, and high-quality care is very difficult without accurate information. Given the importance of the observance of principles of diagnosis recording in clinical records and their educational, therapeutic, research, legal, and statistical application and given lack of knowledge about the existing situation, this research was conducted to determine the rate of observance of principles of diagnosis recording in the clinical records in the hospitals affiliated to Qom University of Medical Sciences.

Methods: This research was conducted as a descriptive-analytical study on medical records of the patients of hospitals affiliated to Qom University of Medical Sciences (including 6 centers) in 2014. The number of statistical sample was estimated to be 398. Data were gathered using a checklist. Data were analyzed by Fisher's exact test and independent t-test.

Results: In this study, assessment of the observance rate of principles of diagnosis recording in medical records, showed that the highest observance was for the observance rate of diagnosis recording principles with 58%. Then, recording principles of medical measures with 50%, and external causes of events with 5.5%, were respectively in the second and third levels.

Conclusion: According to the findings of this study, it seems that more attention and effort of authorities, physicians, and experts of medical records to this issue in the hospitals affiliated to Qom University of Medical Sciences and holding educational classes for physicians, and admission staff and nurses, are necessary.