• Logo
  • SBMUJournals

The Quality of Patients’ Files Documentation in Emergency Department; a Cross Sectional Study

Mehrdad Esmailian, Mohammad Nasr-Esfahani, Amir-Sajad Brahimi



Introduction: Emergency departments as one of the most important wards of hospitals, provide the emergency therapeutic care to decrease the mortality and disability rates among patients. The management and evaluation of emergency activities are possible through timely, accurate, and complete registration of information, based on standard rules. Thus, the aim of this research was detecting the observance rate of documentation standards in the emergency department of Al-Zahra Hospital, Isfahan, to find patients’ files documentation failures and eliminate them. Methods: I This was a cross sectional study performed in the emergency department of Al-Zahra Hospital, Isfahan, 2009. For data gathering, a checklist included 23 questions in two parts was used. The first and second parts had 9 and 14 questions to detect observance rate of patients’ characteristics documentation and nurse reports documentation, respectively. Based on Likert scale, the answer of each option includes blank (score 1), illegible (score 2), incomplete (score 3), and complete (score 4). Therefore, the minimum and maximum reachable scores were determined 9-36 in the documentation of patients’ characteristics and 14-56 in the nurse reports. Data was analyzed using SPSS 8 and Chi-squared test and Fisher’s exact test were applied to compare qualitative data. Student’s t-test was used to compare quantitative information, too. P<0.05 was considered as significant. Results: 300 documents were studied in this research. The average of reached score in the quality assessment of patients record completion was 24.66±17 (15-34), (the maximum reachable score was 36). The total score of emergency patients records was 61.8±4.8 (45-74) from total of 92 reachable scores. The average of total reached score for nurse reports was 37.2±3.7 (28-46), (with the maximum reachable score of 56). No significant difference was seen in the accuracy of patients’ documentation according to referring shift (p=0.37) and being close or not (p=0.61). Conclusion: Based on findings of the present study, status and quality of observance in registration standards of files did not have desirable level. So that most of failures in recording of patients’ characteristics were related to registrations on the file and other indexes; the comments’ signs with date and time documentation and also finishing the comments by the physician were seen, too. Most of documentation failures in nurse reports were related to not finishing the end of report with a straight line, lack of explanation about the cause, status, and type of refer, and not enough statements regarding the patient’s general condition.


Documentation; emergency medicine; patient safety; information management


Zohoor A, Pilevar-zadeh M. Study of speed of offering services in emergency department at Kerman Bahonar hospital in 2000. Journal of Iran University of Medical Sciences 2003;10(35):413-20.

Golaghaie F, Sarmadian H, Rafiie R, Nejat N. A study on waiting time and length of stay of attendants to emergency department of Vali-e-Asr Hospital, Arak-Iran. Arak Medical University Journal (Rahavard Danesh). 2008;11(2):74-83.

Commission J. Hospital accreditation standards. Joint Commission Resources. 2010:17.

RangrazJeddi F, Farzandipour M, Mosavi G. Completion rate of data information in emergency record in Kashan's hospitals. 2004;8(3):68-73.

Naghavi M, Akbari ME. Epidemiology of trauma result from external causes (accidents) in Islamic Republic of Iran. Tehran: Fekrat publications. 2009:249.

Topacoglu H, Karcioglu O, Ozucelik N, et al. Analysis of factors affecting satisfaction in the emergency department: a survey of 1019 patients. Adv Ther. 2004;21(6):380-8.

Olive C. Kobusingye AAH, David Bishai, Eduardo Romero Hicks, Charles Mock, and Manjul Joshipura. Emergency medical systems in low- and middle-income countries: recommendations for action. Bull World Health Organ. 2005;83(8):626–31.

Tavakoli N. Health information management in emergency departments in hospitals affiliated to Isfahan University of medical sciences. Health Information Management journal. 2006;9(42):17-22.

Sedighi M. A survey of record in the case of Hospitals University of medical sciences, Hamadan, Iran. . Journal of medical sciences and health services University of Hamedan. 2006;16(2):45-9.

Mashaufi. Evaluation of recorded data in Ardabil University of medical sciences hospitals. Ardabil University of medical sciences journal. 2001;6(11):43-9.

Mahmoodian S, Alidadi F, Arji G, Ramezani A. Evaluation of Completeness and Legal Aspects` Compliance of Emergency’s Medical Records in Teaching Hospitals of Zabol University of Medical Sciences. Journal of Paramedical Sciences & Rehabilitation. 2014;3(1):33-9.

Ariyaei M. A Survey on the Contents of Medical Records General Hospitals Affiliated with Kerman University of Medical Sciences During the First three Months of 1377. JHA. 2002;4(11):65-70.

Zare Z, Zohoor A. Retracted: Compare the Process of Completion Special Operation Sheets among Medical Teaching Hospitals in Uromia. JHA. 2004;7(15):34-40.


  • There are currently no refbacks.