Documentation in the medical records Hospital National Liver Institute Shebin El Kom Menoufia (An analytical study) | ||
| International Journal of Library and Information Sciences | ||
| Article 6, Volume 2, Issue 3, July 2015, Pages 167-224 PDF (2.04 M) | ||
| Document Type: Original Article | ||
| DOI: 10.21608/ijlis.2015.64490 | ||
| Author | ||
| Mariem Saleh Mansour | ||
| 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. | ||
| Keywords | ||
| Documentation; medical records; National Liver Institute | ||
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