The Quality of health records used in the processing of Lawsuit Cases, a Study in Zabol, Iran

  • Abbas Sheikhtaheri Department of Health Information Management, School of Health Management and Information Sciences, Iran University of Medical Sciences, Tehran, Iran
  • Ali Aliabadi PhD student of Health Information Management, Department of Health Information Management, School of Health Management and Information Sciences, Iran University of Medical Sciences, Tehran, Iran
  • Samaneh Saravani Aval Department of Health Information Technology, School of Allied, Zabol University of Medical Sciences, zabol, Iran
Keywords: forensic medicine, health records quality, documentation

Abstract

Background: Forensics is one of the most important areas for the use of health records. Annually, thousands of people refer to forensic medicine organizations to receive health records relating to assaults, accidents, conflicts, medical malpractice, examining the corpse, and clinical examinations. The purpose of this study was to analyze the quality of health records that were used in Zabol Department of Forensic Medicine.

Method: In this descriptive cross-sectional study, five hundred health records in total were examined. Data were extracted from health records archived in the Department of Forensic Medicine. Data was collected using a checklist. Data were analyzed by SPSS18 software program.

Results: The results showed that 71.2% of the lawsuits were associated with accidents. As for ineffectiveness of the health records, 415 cases (83%) and 441 cases (88.2%) were associated with inaccuracies and incompletely collected information, while 149 cases (29.8%) were associated with the lack of signature and sealing.

Conclusion: The quality of the health records under study was not acceptable and despite the importance of legally correct documentation, information was defective. Medical records’ documentation has numerous weak points in terms of accuracy, completeness, consistency, and being signed and sealed.

Published
2018-07-02
Section
Research Articles