Correction of patient medical record errors through a file control method

• Published in: Health policy and technology 2019-12, Vol.8 (4), p.329-336
• Main Authors: Sungur, Cuma, Sonğur, Levent, Çiçek, Ayşegül Çopur, Top, Mehmet
• Format: Article
• Language: English
• Subjects: Electronic medical records; File control; Medical informatics; Medical record errors; Patient files
• ISSN: 2211-8837; 2211-8845
• DOI: 10.1016/j.hlpt.2019.08.010

•This study has determined that as a result of the file review, errors in medical records will be reduced by a pre-determined amount.•This is the first research in Turkey that makes mistakes in the medical patient records based on examining the patient file.•The integration of the hospitalization consent form into the hospital information management system was recommended.•This study demonstrated the importance of training in reducing medical records and patient file errors. The purpose of this study was to reduce the errors that might occur in the medical practice records to the lowest possible level, thereby contributing to a better quality of health care services. The aim of this study is to reduce the errors and deficiencies in the patient files by providing training related to medical records and patient files to the personnel who are responsible for filling the patient files. This study was based on medical record errors in patient files. The study was carried out in a training and research hospital in the Turkish health sector, and 360 physicians, nurses, and medical secretaries took part. In this context, the mistakes in the patient files were monitored and recorded, the recordings were analyzed to determine error areas, and the participants were trained to enter patient files correctly and completely. The error-free patient file rate was 9% in the first month of the study. In the second month of the study, the participants were trained to properly complete the patient's files. The error-free patient files rate increased to 35%, 41%, 69% in the second, third, and fourth month of the study, respectively. Our data demonstrate the importance of educating health workers to prevent mistakes in medical records. Our data also demonstrate the necessity of using electronic medical recording systems. All health institutions should move into regular, accurate, and complete recording systems to prevent medical errors that might arise in terms of patient and employee safety, thereby helping to fulfill their legal responsibilities.