Designing a model for medical documentation as per joint commission international in emergency department of Tabriz Imam Reza hospital

Abstract

Medical record documentation is an important legal and professional requirement for all health professionals which ensures holistic patient care presented to him. The aim of this study was evaluation of medical documentation in emergency ward of Emam Reza Hospital as per joint commission international. In a cross sectional and descriptive analytical study that performed in emergency department of Tabriz University of Medical Science, medical documentation in emergency ward of Emam Reza Hospital as per joint commission international evaluated. In all records, details of patient information and report was recorded. Physician stamp was recorded all documents. The physician's signature in 534 cases had been recorded. Special consent was found in 24 patients that including, 3 special consent for tpa and 18 special consent for the surgery. In the documents of 24 patients with special consent in all cases, name and signature of patient, signature of witness with date, physician's signature with date and surgery/treatment indication was recorded in documents. Date, time and physician's signature in 486 cases and daily physician record's were done in 564 documents. Date, time, nurse's signature and daily physician record's were done in all documents. Chief compliant of patient, pervious history and physical examination were recorded in 36 cases at documents. Medication treatment in 167 cases, discharge status in 557 cases, date or time of further follow-up in 485 cases, prescribing or any recommending at discharge in 453 cases and physician's signature in all cases were recorded in documents. The survey was conducted on the medical records documenting in the study, documentation in the medical records of patients in the emergency department had more compliance with JCI standards. In cases with defect, researchers give training to physician, nurses and emergency admission personals to optimization of such action. é Medwell Journals, 2014.