تاثیر گنجاندن ستون «خلاصه‌ی سیر بیماری» در صفحه‌ی دستورات پرونده‌های بیمارستانی بر افزایش ثبت سیر بیماری

Introduction: medical records consist of documents evidencing a patient's health status at amoment of life. there is a close relationship between disease progress and daily physician ordersissued in medical records. each order in fact reflects the patient's medical status and his/herdisease progress. in this study, while keeping the previous progress page in the records, a columnof brief disease progress was included in physician order sheets to increase the quality of recordsand promote the education of learners.methods: in this cross-sectional controlled interventional study, medical records of all patientsadmitted to super specialty wards of amirkola children hospital during the first quarters of 2009and 2010 were included. from a total of 3462 records, 150 records were studied each year. eachindicator of disease progress, which was recorded based on subjective, objective, assessment, andplan (soap) note, was given a score. finally, if only three indicators were mentioned in therecord, it was considered as poor. scores 4-5 represented moderate and scores 6-7 wereconsidered as good. the scores of the records were then compared using statistical tests includingt-test, paired t-test, pearson's correlation coefficient, chi-square test, fisher's exact test, andkappa coefficient. p values less than 0.05 were considered as significant.results: the mean number of physician orders in records during the first quarters of 2009 and2010 were respectively 9.15 ± 10.8 and 8.45 ± 6.80 cases. good scores had the highest frequencyin the new brief disease progress form. the highest average of results in the studied groups wasobserved in brief disease progress notes of 2010. comparison of mean scores revealedstatistically significant differences (p < 0.05).conclusion: adding a new column named brief disease progressive note in physician ordersheets significantly promoted the recording of disease progress and reasons for medical ordersbased on soap note. therefore, it is recommended to include this column in physicianorder sheets.keywords: medical records; progressive note; physician order sheet; documentation.