. Nahid Tavakoli; . Maryam Jahanbakhsh; . Mojtaba Akbari; . Mojtba Baktashian; . Akbar Hasanzadeh; . Samaneh Sadeghpour
Volume 5, Issue 3 , May 2015, , Pages 1-6
Abstract
Background: The rate of hospital deductions is a commonly cited concern among teachinghospitals in Iran. The objective of the present study is to access the effect of the quantitativeand ...
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Background: The rate of hospital deductions is a commonly cited concern among teachinghospitals in Iran. The objective of the present study is to access the effect of the quantitativeand qualitative analysis of inpatient medical records on deductions and identifying the majorresources of deductions. There are currently no published interventional studies that haveinvestigated this issue quantitatively. Materials and Methods: In an interventional study,we reviewed all the 192 patient’s medical records (PMRs) for any documentation errors, todetermine the rate of deductions. We conducted a pilot of 30 cases prior to the actual survey.Nonprobability‑based consecutive sampling was used. The main study was conducted in threephases: 1. Primary evaluation; 2. Training, performance of intervention and corrective actions;and 3. Final assessment. Comprehensive assessments of medical records and follow‑up oferror correction were carried out systematically and according to the pre‑set schedule. Pre‑ andpost‑intervention assessments were compared in order to evaluate the effect of the intervention.Data were analyzed using the SPSS‑20 statistical software. Paired‑sample t‑test was used tocompare changes in deduction scores before and after the intervention. Differences at a P valueless than 0.05 were considered statistically significant. Results: In the initial survey of 800 PMRs,nearly one quarter (24%) (Or 192 cases) had at least one type of deduction. The three top typesof deductions were Laboratory (47.9%), Medical radiation (45.3%), and Physician visit (35.9%).The results showed a 2.7‑ to about 36‑fold lower rate of hospital deductions (average: 6.4‑fold;reduction from 21131 to 3285 US dollars). Conclusion: All in all, the results of the present studyindicated that educational interventions and quantitative and qualitative analysis of inpatientmedical records are very beneficial and effective in the reduction of medical record deductions.