INTRODUCTION

It has long been recognised that accurate and complete documentation is important in medicine.[1] International Classification of Diseases (ICD)’s guidelines have announced that diagnostic information should be organized systematically utilizing standardized recording methods.[2] Nevertheless inaccurate and incomplete medical records remain a worldwide problem. A systematic review showed that many countries have been complaining for incompleteness, inappropriateness and illegibility of records.[3,4] In recent years, many high level health and safety planning strategies have tried to determine the factors that improve the quality of medical care.[5] One of the key requirements of high quality medical care is the documentation of: the patient’s health status, the time of entry of all the information about patient’s hospitalization, lab tests and imaging modalities needed, the patient’s clinical progress, and the availability of family support.[6]

2.1 预防试验结果 由表1可知，在预防试验中，Ⅰ～Ⅵ组发病鸡的症状基本一致,为典型的IBD病变,血清检查结果呈阳性；对照组雏鸡发病率明显高于试验组；Ⅵ组因未服用中草药制剂，发病率高且病情最严重,试验期内7只雏鸡发病，发病率高达17.5%。Ⅳ组雏鸡发病症状最轻且发病率最低，试验期内仅有1只雏鸡发病，发病率为2.5%，将制得的复方中草药制剂按4.0 mL/只服用，预防效果最好，表明中草药制剂对雏鸡IBD有明显的预防效果。

Instructive interventions have been shown to improve the documentation entered into medical records significantly.[7,8] The American Health Information Management Association (AHIMA) claims that training programs are one of the most effective ways to improve the documentation process.[9] It also suggests that; using incentive program, updating and redesigning medical forms, frequently reviewing records and providing physicians with the best and most appropriate time to access and complete medical records, are the most useful practices to improve documentation.[9] In Iran, in the last two decades external evaluation systems affected the health care systems seriously. Government, ministry of health, consumer services, insurance companies etc. all are working hard together to meet the world standards of optimal patient care. Accreditation, is one of the modalities to help in this field by improving quality health care services.[10,11] This study was designed to examine whether a simple educational intervention (i.e.,a training workshop) would improve the documentation of medical records performed by PGY1 emergency medicine residents. Our hypothesis is that education can have a positive effect on medical record documentation.

是马太太话里有话，还是她神经过敏？佳芝心里想。看他笑嘻嘻的神气，也甚至于马太太这话还带点讨好的意味，知道他想人知道，恨不得要人家取笑他两句。也难说，再深沉的人，有时候也会得意忘形起来。

METHODS

Study design

This interventional “before and after” study was conducted in 2015 in Imam Khomeini, Shariati and Sina hospitals. We evaluated the effectiveness of a 3-dayeducational workshop for emergency medicine residents on the information required to produce an accurate and complete medical record.

The principles of documentation taught in the workshop were based on the latest WHO and AHIMA guidelines.[9] The correct methods of documentation and the necessary parts documented were emphasized in this workshop. This teaching course was instructed by the chief investigator. At the end of workshop, as a practical exam, some old medical files, without the patient’s identity, were evaluated by the participants and all missing or incomplete data were determined and discussed.

Some of the medical records documented by the residents were randomly selected before, 1 month and 6 months after they attended the workshop and their quality compared.

Thirty PGY1 emergency medicine residents attended the workshop and participated in the study. Medical records documentation of the same residents were evaluated. The medical records of 300 patients registered by these residents (i.e., 10 records per resident) were collected randomly before holding the workshop, 300 medical records (i.e., 10 records per resident) were selected randomly one month after the workshop, and a further 300 medical records were again randomly selected six months after the workshop. These 900 medical records were then scored by three trained colleagues who were blinded to patients’ and residents’identities. They checked all the items below and fulfilled a predesigned checklist, like previously described studies.[5,7,12] Briefly, scoring was performed by using standard checklists that contained yes/no answers to the following questions (Table 1).

结果显示，随着三棱、莪术提取物质量浓度的增加，其对SW620细胞的抑制率也相应升高。不同质量浓度三棱、莪术提取物作用后的细胞增殖抑制曲线见图1。根据该曲线求算得三棱提取物IC30为3.24 μg/mL，IC50为4.69 μg/mL；莪术提取物IC30为11.27 μg/mL，IC50为16.81 μg/mL。

Statistical analysis

Our study revealed that documentation of most items was improved significantly after the workshop. Data are shown in Table 2. The most accurately documented items before the intervention were patients’ identity, first and final diagnosis and compatibility of medical orders with patient diagnosis.

RESULTS

All data were analyzed by SPSS v.22. For qualitative data the frequency rate and for quantitative data the mean±SD were reported. In order to evaluate the normal distribution of quantitative data, we conducted a Kolmogorov-Smirnov (KS) test. We then performed the independent t test to compare our quantitative data,which had a normal distribution, with 95% CI. All the descriptive data were analyzed by Chi-Square test.P-value ＜0.05 was statistically significant.

Emergency overcrowding and physicians’ burnout are confounding factors in documentation. Our checklist evaluation could not confirm the accuracy of all the data documented in each record. The emergency medicine residents that participated in the study were volunteers and, therefore, may have been more likely to respond positively to the educational workshop than the remainder of their colleagues who did not did consent to participate in the study.

Registration of patients’ family history was significantly decreased after the intervention.

This study confirms that an educational workshop improves medical record documentation by physicians in training. More educational workshops with short time intervals might have a better outcome. Physicians might pay attention more on documenting the items they are interested in or they find them more important. Education can teach them to register all necessary items accurately in the medical files.

Table 1. The standard checklists

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DISCUSSION

原“增值税留抵税额”明细科目因国家税务总局2016年第75号公告的规定，完成其过度性功能予以取消。其他明细科目及专项核算内容依照新规定。

Medical records are essential for the provision of high quality medical care for patients and legal evidence.The content of these records should be accurate and complete. Education is required so that physicians know what information must be accurately and completely documented in the medical record.[7,8] This study shows that the quality of documentation was increased significantly after an educational workshop. In this study we found that education could increases the rate of documentation in most components of medical data.The most dramatically observed changes were in the documentation of systematic physical exam both 1 and 6 months after the workshop and also documentation of date and time 6 months after the workshop. It seemed that EM residents did not pay attention to correctly documenting some items like diagnostic plan and treatment options, lab tests and imaging reports,differential diagnosis, problem list, on service and off service notes. Their medical orders had a good and correct compatibility with patients’ diagnosis and first and final diagnosis were accurately documented from the beginning of the study. We observed that 1 month after the intervention, documentation of some items was a little higher than that after 6 months of the study.The closer to the workshop the results were evaluated,the more positive effect was seen on the documentation rate. Ala et al[6] in 2014, evaluated medical record documentation in an ED. They reported that details of patient information and physician stamp were recorded in all documents but most of other notes like consent form, surgical notes were less accurately documented.They also showed that nursing notes and documentation were almost complete. Khoshbaten et al[13] in 2010 also showed that a training workshop had a positive effect on medical record documentation. The same result was observed in multiple other studies.[14,15] In 2005,Farokhi et al[16] evaluated the effect of an educational workshop on medical record documentation. They found that documentation of medical history, consult papers,progress notes and other brief reports were significantly improved after the intervention. Tavakoli et al[14] in 2015 published that the main reason for the low quality of medical records was lack of education. Our study showed that further studies with more expand evaluation in different specialties are needed to con fi rm the positive effect of education on medical record documentation.This study declared that education could effectively improve documentation specially with repeated and short training intervals. Residents seemed to be more interested in the documentation of some items or they might consider these items more important. For example we found that they ordered and checked lab tests andimaging but they did not pay attention to document the reports of them because of inadvertence or laziness or lack of time. There is little previous research addressed the quality of documentation. Some have suggested chart-based educational training while others have recommended using workshops. There are studies[17-19]confirming that educational intervention can be an effective means of improving providers’ behaviour regarding medical record documentation. Farzandipour et al[20] in 2013, found that one brief educational session was not an effective strategy to improve documentation.Tinsley et al[19] declared that documentation might be improved by education if it was reinforced with support of faculty and continued feedback to trainees about their charting quality. Our study somehow supported this result and con firmed that 6 months after the intervention some documentation rates faded comparing to 1 month following the educational workshop. O’Brien et al[21] supported this finding that a documentation was strengthened by relevant feedbacks or reminders.

Table 2. Comparison of medical records documentation before and after the intervention (Total number of files in each interval=300)

Items Before workshop　1 month after workshop 6 months after workshop　P-value 95% CIP-value* 95% CI Progress note　228 (76.0%)　298 (99.3%)　295 (98.3%)　　＜0.001　　＜0.001 Compatibility of medical orders with patient diagnosis 297 (99.0%)　297 (99.0%)　300 (100.0%)　 0.6　 0.1 First and final diagnosis　298 (99.3%)　297 (99.0%)　300 (100.0%)　 0.6　 0.2 Consulting order　257 (85.7%)　296 (98.7%)　300 (100.0%)　＜0.001　　＜0.001 Patient identity　273 (91.0%)　290 (96.7%)　300 (100.0%)　 0.004　　＜0.001 Vital signs　206 (68.7%)　272 (90.7%)　268 (89.3%)　　＜0.001　　＜0.001 Systematic physical exam　134 (44.7%)　266 (88.7%)　267 (89.0%)　　＜0.001　　＜0.001 Chief complaint　235 (78.3%)　263 (87.7%)　266 (88.7%)　 0.002　　＜0.001 Physician signature and stamp　200 (66.7%)　249 (83.0%)　276 (92.0%)　　＜0.001　　＜0.001 Drug history　126 (42.0%)　138 (46.0%)　181 (60.3%)　 0.3　　＜0.001 Past medical and habitual histories　 47 (15.7%)　109 (36.3%)　 85 (28.3%)　　＜0.001　　＜0.001 Date and time　 74 (24.7%)　 63 (21.0%)　269 (89.7%)　 0.2　　＜0.001 Differential diagnosis 　 51 (17.0%)　 59 (19.7%)　 50 (16.7%)　 0.3　 0.9 Problem list　 55 (18.3%)　 55 (18.3%)　 44 (14.7%)　 0.5　 0.2 On service and off service notes　 32 (10.6%)　 41 (13.6%)　 39 (13.0%)　 0.4　 0.3 Family history　143 (47.7%)　 34 (11.3%)　 63 (21.0%)　　＜0.001　　＜0.001 Diagnostic plan and treatment options　 43 (14.3%)　 31 (10.3%)　 32 (10.7%)　 0.1　 0.1 Lab tests and imaging reports Lab data　 14 (4.7%)　 23 (7.7%)　 22 (7.3%)　 0.1　 0.1 Imaging　 8 (2.7%)　 20 (6.7%)　 13 (4.3%)　 0.02　 0.2 ECG　 2 (0.7%)　 6 (2.0%)　 5 (1.7%)　 0.2　 0.3

Limitations of the study

The most dramatically changed items were:documentation of systematic physical exam both 1 and 6 months after the workshop and documentation of date and time 6 months after the workshop.

CONCLUSIONS

Documentation of diagnostic plan and treatment options, lab tests and imaging reports, differential diagnosis, problem list, on service and off service notes were poor both before and after the intervention, thus workshop could not help physicians to augment theirdocumentation in these items. About the “Compatibility of medical orders with patient diagnosis” and “First and final diagnosis”, the study showed no difference before and after the intervention because their registration was almost complete from the beginning.

4.2 施肥习惯：重施有机肥、足施磷钾肥、少施氮肥，比少施或不施有机肥、磷钾肥用量不足、氮肥施用过量的地块，整体发病危害轻，配方施肥比常规施肥的发病轻。

Funding: None.

Ethical approval: Not needed.

Conflicts of interest: Each author of this manuscript does not have any conflict of interest.

Contributors: HSV study design; MM data gathering and study design; EV data analysis; HSM critical revision.

REFERENCES

1 Gutheil TG. Fundamentals of medical record documentation.Psychiatry (Edgmont). 2004;1(3):26-8.

2 International classification of diseases (ICD) [Internet]. WHO.2010.

3 Rooney AL. OPR. Licensure, accreditation, and certification:approaches to health services quality. Bethesda: Quality Assurance Project; 1999;62.

4 Adane K, Muluye D, Abebe M. Processing medical data: a systematic review. Arch Public Health. 2013;71(1):27.

5 Mashoofi MAF, Rostami KH, Mardi A. Survey on evaluation of information charting in hospitals of Ardebil University of Medical Science. Journal of Ardebil University of Medical Sciences. 2004;4(11):43-9.

6 Ala A, Moharamzadeh P, Pouraghaei M, Almasi A, Mashrabi O. Designing a model for medical documentation as per Joint Commission International in Emergency Department of Tabriz Imam Reza Hospital. Research Journal of Applied Sciences.2014;9(8): 543-8.

7 Tinsley JA. An educational intervention to improve residents'inpatient charting. Acad Psychiatr. 2004;28(2):136-9.

8 Socolar RRS, Raines B, Chen-Mok M, Runyan DK, Green C,Paterno S. Intervention to improve physician documentation and knowledge of child sexual abuse: A randomized, controlled trial.Pediatrics. 1998;101(5):817-24.

9 AHIMA long term care Health Information Practice &Documentation Guidelines [Internet]. Foundation of research and education. American Health Information Management Association. 2011. Available from: http://library.ahima.org/xpedio/groups/public/documents/ahima/alt_bok2_000136.hcsp?dDocName=alt_ bok2_000136

10 Scrivens E. International trends in accreditation. Int J Health Plann Manage. 1995;10(3):165-81.

11 Raeisi AR, Yarmohammadiyan MH. A comparative study of accreditation information models in Europe and America. J Health Inf Manag. 2007;3(2):19.

12 Seyf Rabiei MA, Mazdeh MD, Dadras F, Shokouhi Solgi M,Moradi A. Study of hospital records registration in teaching hospitals of Hamadan University of Medical Sciences in 2009.Scientific Journal of Hamadan University of Medical Sciences and Health Services 2009;16(2):45-9.

13 Khoshbaten M EM, IsazadeFar KH, GhafaruFard S.Determination of re-education students and the faculty role in the improvement of medical record data files , proceeding of the 10th medical science education. Specialty Journal of Medical Education. 2010;6(1):23-4.

14 Tavakoli N, Jahanbakhsh M, Akbari M, Baktashian M,Hasanzadeh A, Sadeghpour S. The study of inpatient medical records on hospital eductions: An interventional study. J Educ Health Promot. 2015;4:38.

15 Purdom DT, Griffith RS, Weaver DL. A positive, systematic approach to improve inpatient medical record completion in a family practice residency program. Fam Med. 1996;28(6):411-4.

16 Farokhi SMM, Rasoulzadeh B. Effect of training workshop on writing a medical record for internship students of Azad and general universities of Ardabil. Iranian Journal of Medical Education. 2005(14):15.

17 Esmaeili MR AH, Mohammadi Kenari H. Comparison of medical students’ and pediatric residents’ practices in medical records at Amirkola Children’s Hospital. Journal of Babol University of Medical Sciences. 2010;12:106-11.

18 Seyf Rabiei MA SI, Mazdeh MD. Study of hospital records registration in teaching hospitals of Hamadan University of Medical Sciences in 2009. Scientific Journal of Hamadan University of Medical Sciences and Health Services. 2009;16:45-9.

19 Jeanmonod R, Katz B. Error reporting in the emergency department: do we do what we say we do? World J Emerg Med.2012;3(4):261-4.

20 Farzandipour MMZ, Rangraz Jeddi F, Gilasi H, Shokrizadeh Arani L, Fakharian E, Saddik B. A pilot study of the impact of an educational intervention aimed at improving medical record documentation. J R Coll Physicians Edinb. 2013;43(1):29-34.

21 O'Brien KE, Chandramohan V, Nelson DA, Fischer JR, Stevens G, Poremba JA. Effect of a physician-directed educational campaign on performance of proper diabetic foot exams in an outpatient setting. J Gen Intern Med. 2003;18(4):258-65.