Medical record documentation quality in the hospital accreditation
Saiedeh Sharifi, Mansour Zahiri, Hosein Dargahi, Farzad Faraji Khiavi
Abstract
BACKGROUND: Medical records constitute a legal and professional document regarding the activities of medical staff in hospitals. This study was conducted with the aim of identifying the factors that affect the quality of medical records by implementing the accreditation models in hospitals. MATERIALS AND METHODS: This was a qualitative study. The data were collected via 28 semi-structured interviews. The research population included administrators and supervisors of nursing, medical records and accreditation in educational hospitals in Ahvaz, southwest Iran. Content analysis method was used to analyze the data. Descriptive statistics were used to present demographic characteristics of interviewees. RESULTS: Facilitators and barriers to improve the quality of documentation were categorized into three levels: organizational, environmental, and personal, all achieved after the implementation of accreditation model in hospitals. Six facilitating factors were identified including organizational structure, organizational culture, management support, individual characteristics, and perceived benefits science and technology. The barriers included five factors including program structure, organizational structure, beliefs, justice, and individual characteristics. CONCLUSIONS: The identification of factors affects the quality of medical record documentation and it seems that health managers and policymakers should take measures to improve the quality of medical recording documentation through strengthening the facilitators and overcoming the barriers in the program since the purpose of accreditation is to improve the quality in hospitals.