The Quality of health records used in the processing of Lawsuit Cases, a Study in Zabol, Iran
Keywords:forensic medicine, health records quality, documentation
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 recordsâ€™ documentation has numerous weak points in terms of accuracy, completeness, consistency, and being signed and sealed.
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