التوثيق في السجلات الطبية بمستشفى معهد القومي الكبد القومي بشبين الكوم محافظة المنوفية : دراسة تحليلية

الملخص EN

The study sought to analyze and monitor the accuracy and completeness and comprehensiveness of the documentation in medical records Hospital National Liver Institute, and the extent of its conformity with local and international standards, through testing and analysis of (400) record from the medical records of outpatient and inputpatient in the di study departments (liver disease, children, surgery).

One of results of the study that documented in the medical records Hospital National Liver Institute does not meet local and international standards by 65%.

The study recommended the necessity of commitment to l|)cal and international standards and develops a strategy for the management of health information at the state level.

Both medical students and nursing should have a curriculum for documentation in the medical Vecords, to reduce medical errors.

Work on the application of the electronic medical record system to get rid of manual documentation problems