Medical record documentation quality in the hospital accreditation
نویسندگان
1 Department of Health Services Management, School of Health, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran
2 Department of Health Services Management, School of Health, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran
3 Department of Health Services Management, School of Health, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran, Social Determinants of Health Research Center, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran
4 Department of Management Sciences and Health Economics, School of Public Health, Health Information Management Research Center, Tehran University of Medical Sciences, Tehran, Iran
doi
چکیده
BACKGROUND: Medical records constitute a legal and professional document regarding the activitiesof medical staff in hospitals. This study was conducted with the aim of identifying the factors thataffect the quality of medical records by implementing the accreditation models in hospitals.MATERIALS AND METHODS: This was a qualitative study. The data were collected via28 semi‑structured interviews. The research population included administrators and supervisorsof 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 presentdemographic characteristics of interviewees.RESULTS: Facilitators and barriers to improve the quality of documentation were categorized intothree levels: organizational, environmental, and personal, all achieved after the implementationof accreditation model in hospitals. Six facilitating factors were identified including organizationalstructure, organizational culture, management support, individual characteristics, and perceivedbenefits 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 documentationand it seems that health managers and policymakers should take measures to improve the quality ofmedical recording documentation through strengthening the facilitators and overcoming the barriersin the program since the purpose of accreditation is to improve the quality in hospitals.
