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MISCONDUCT IN MEDICAL RECORDS DOCUMENTATION OF PATIENTS ADMITTED TO SURGICAL DEPARTMENT AT BASRAH GENERAL HOSPITAL. A CROSS SECTIONAL STUDY OF 250 MEDICAL RECORDS

Author: Salim Mahdi Al-Bassam
Journal: Basrah Journal of Surgery مجلة البصرة الجراحية ISSN: 16833589 / ONLINE 2409501X Year: 2016 Volume: 22 Issue: 1 Pages: 8-16
Publisher: Basrah University جامعة البصرة

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Abstract

Abstract Medical health records form an essential part of a patient’s present and future health care, so proper recording and documentation is mandatory because improper record keeping can result in poor management as well as declining medical claims. The aim of this study is to evaluate the degree of writing patient's medical records and the adherence of medical staff to document patients' information's in accurate and proper manner as a guide for management protocols. This is a retrospective descriptive cross sectional study, carried out in Al-Basrah General Hospital from 1st of January to 15th of February 2015, 250 medical records randomly selected, admitted for both urgent and elective surgeries from the total number of records registered at 2015, The Information from the records are documented on scoring questionnaire arrange by the researchers. The documentation varies from item to other, for information related to patient identity: name, address, occupation presented completely in 70%, 19.2%, and 60.9% respectively. Regarding medical history, the chief complaint was written in medical term in 39.2% while the duration of illness was documented in 57.2%, whereas present illness, review of system, past, social, family & drugs histories were completely presented in 17.6%, 1.6%, 19.6%, 3.6%, 2%, 20.8% respectively. 38.8 % for general examination, 66% for systemic examination, 32.4% for vital signs, 94.8 % for preoperative & operative anesthetic notes, and 46.8% for operative surgeon notes were not presented at all. The investigations & treatment present in 71.6% & 56.8% respectively while diagnosis was not mentioned in 87.4%. Regarding follow up, nursing notes, consent were not present in approximately 30% of data. The admission sheet was not present in 2.8% while discharging summary report was not present in 97.2%. For diet, height, weight, fluid chart were not recorded in 100%. A comparison between urgent & elective surgeries reveals that the recording was slightly better for elective but this is not statistically significant. The documentation of patient medical records in surgical department of Al-Basrah General Hospital is poor, the majority of sheets in the records lack most of Information that its presence is fundamental for patient management, and the majority of data are not documented in complete and proper manner.


Article
An Anxiety and Salivary Cortisol Correlation in Dental Managements between Different Dental Departments
العلاقة بين التوتر ومستوى الكورتزول في اللعاب خلال عمليات العلاج بين مختلف اقسام طب الاسنان

Author: Ahmad Fliah Hassan احمد فليح حسن
Journal: Al-Rafidain University College For Sciences مجلة كلية الرافدين الجامعة للعلوم ISSN: 16816870 Year: 2015 Issue: 35 Pages: 343-356
Publisher: Rafidain University College كلية الرافدين الجامعة

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Abstract

Stress is a normal psychological and physical reaction to the ever-increasing demands of life. Studies show that many challenges with stress at some point during the year. Seventy five Iraqi dental patients interning collage of dentistry divided in three groups, twenty five patients were admitted to oral medicine and diagnosis department, twenty five patients to periodontal department and the last twenty five patients were to oral surgical department. Each selected group was compared to the each other groups. The parameters of comparison were dental anxiety scale and salivary cortisol. The research was based on evaluation of salivary cortisol and modified dental anxiety scale (MDAS). The cortisol evaluation was achieved using ELISA technique while, MDAS were based on scoring questionnaire.The salivary cortisol levels and MDAS were ranges from 0.243±0.190 ng/L to 7.760±2.488 with a significant changes 0.0001 (p<0.05) in the oral surgery department. The collected cortisol level and MDAS were 0.274±0.273ng/L to 9.000±3.617 in periodontal department with a significant changes 0.0001 (p<0.05), while the diagnosis department showed a cortisol changes between 0.178±0.132 ng/L to 7.240±2.385 with significant changes 0.0001 (p<0.05).We concluded that the relations between the anxiety-fear of the patients were significantly changed and strongly related to the type of treatments ; we confirmed that by using MDAS according to the dental treatment in a different departments (oral medicine and diagnosis, periodontal and oral surgery) in compared with salivary cortisol level.The diagnosis department showed the lower values in salivary cortisol and MDAS with high correlation, while the higher values were recorded in periodontal department. MDAS was an effective tool in monitoring an anxiety for the patients. Types and applying of dental instruments were associated with anxiety.

ان الهدف من هذه الدراسة هو بيان درجة الخوف لمرضى الاسنان وعلاقتة بنسبة الكورتزون المقاس من اللعاب لثلاث عينات من المرضى تمت معالجتهم في ثلاثة فروع علاجية في كلية طب الاسنان- الجامعة المستنصرية.شارك في هذه الدراسة خمسة وسبعون مريضا. خمسة وعشرون مريضا تمث معالجتهم في كل قسم (جراحة الفم و امراض وجراحة ماحول الاسنان والتشخيص الفمي). وزع على المرضى استبيان معدل لقياس الخوف من علاج الاسنان مع اخذ عينة من اللعاب من اجل قياس نسبة الكورتزون لغرض معرفة العلاقة الاحصائية بينهما.اظهرت النتائج الاحصائية ان المرضى الذين يعالجون في قسم امراض وجراحة ماحول الاسنان هم الاكثر خوفا، يليهم المرضى المعالجين في قسم جراحة الفم وقد كان المرضى المعالجين في قسم التشخيص الفمي هم الاقل تخوفا حسب النتائج الاحصائية بين مجموعة واخرى حسب نتائج الاستبيان والكورتزون المقاس من اللعاب وارتباطها بالقسم الذي تم العلاج به وذلك يعود لعدة اسباب منها طول فترت انتظار المرض ومعرفته او عدم معرفته بنوع العلاج المقدم له وطبيعة المواد المستخدمة في العلاج.

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