其他摘要：Background: Documentation of medical data in patient records is needed to improve the quality of healthcare and medical knowledge progress. Documentation of patient history, clinical problems, treatment, and follow-up care are needed to improve practice and research. Objective: To determine documentation of patient records at the internal medicine ward of Imam Khomeini Hospital, Tabriz, Iran. Method: The study was descriptive and 100 patient records were selected through random sampling. Records were related to the patients who had been discharged from the general internal ward during April to June 2000. Data was collected using the questionnaire including 30 closed questions, and 5 open ones. The results were reported in ratios (%) averages and standard deviation. T-test was used to examine the association of length of stay and records data adequacy scores. Data was analysed by the SPSS software. Results: Completeness of the patient records was moderately acceptable (68.7%). The difference between performance of residents, interns and students in documentation of primary diagnoses and differential diagnoses was significant (P<0.001) and performance of residents was more efficient (59.6%), (69.7%). Of the records, 22.2% were without summary sheet. Conclusion: Patient records had many deficiencies. Instructions for documentation are necessary. Regular monitoring and evaluation by the attending physicians and writing skills education could be effective in accurate documentation. Key words: DOCUMENTATION, MEDICAL RECORDS, REVIEW, TEACHING HOSPITALS, TABRIZ
