Documentation in the medical records Hospital National Liver Institute Shebin El Kom Menoufia (An analytical study)

Document Type : Original Article

Author

قسم المکتبات والمعلومات جامعة المنوفية

Abstract

The study sought to analyze and monitor the accuracy and
completeness and comprehensiveness of the documentation in medical
records Hospital National Liver Institute, and the extent of its conformity
with local and international standards, through testing and analysis of
(400) record from the medical records of outpatient and inputpatient in the
study departments (liver disease, children, surgery). One of results of the
study that documented in the medical records Hospital National Liver
Institute does not meet local and international standards by 65%. The
study recommended the necessity of commitment to local and
international standards and develops a strategy for the management of
health information at the state level. Both medical students and nursing
should have a curriculum for documentation in the medical records, to
reduce medical errors. Work on the application of the electronic medical
record system to get rid of manual documentation problems.

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