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The Completeness of Medical Record at Provincial Hospitals in Central Part of Thailand, Ministry of Public Health

หน่วยงาน ฐานข้อมูลวิทยานิพนธ์ไทย

รายละเอียด

ชื่อเรื่อง : The Completeness of Medical Record at Provincial Hospitals in Central Part of Thailand, Ministry of Public Health
นักวิจัย : Saray Ruangdej
คำค้น : -
หน่วยงาน : ฐานข้อมูลวิทยานิพนธ์ไทย
ผู้ร่วมงาน : -
ปีพิมพ์ : 2536
อ้างอิง : http://www.thaithesis.org/detail.php?id=40719
ที่มา : -
ความเชี่ยวชาญ : -
ความสัมพันธ์ : -
ขอบเขตของเนื้อหา : -
บทคัดย่อ/คำอธิบาย :

The objective of this survey research was to study the completeness of Medical Record at Provincial Hospitals in Central Part of Thailand which is devided into 4 regions. The twelve sampling hospitals were selected from the second and third regions by two - stage sampling method. The Medical Records to be examined were 1,534 files for the outpatient medical record and 1,532 files for the inpatient medical record. The tool for data collection was a checklist that was adapted from theory and from the Ministry of Public Health forms. The analysis showed that the mean of completeness of outpatient medical record was 65.17 %, general inpatient medical record was 73.02 %, and obstetric inpatient medical record was 75.74 %. For outpatient medical record, the percental means of completeness data were as followed: personal data was 89.98, chief complaint was 83.44, medical history was 27.79, physical examination was 32.09, laboratory was 67.57, X-ray was 50.00, diagnosis was 68.38, treatment was 73.58, doctors signature was 93.68. For the general inpatient medical record, the percental means of completeness data were as followed: personal data was 97.51, medical history was 66.69, physical examination was 63.20, laboratory was 85.01, X-ray was 81.59, provisional diagnosis was 17.16, final diagnosis was 97.78, doctors order was 94.74, progress note was 14.11, nursesnote was 86.89, medication record was 97.09, T.P.R. record was 88.78, operative note was 58.64, anaesthesia record was 80.54, authorization form was 64.50, summary sheet was 88.28. For obstetric inpatient medical record, the percental means of completeness data were as followed: personal data was 89.92, medical history was 74.25, physical examination was 32.64, laboratory was 84.17, doctors order was 93.64, progress note was 16.66, nurses note was 95.20, medication record was 95.78, T.P.R. record was 93.02, operative note was 35.30, anaesthesia record was 95.20, authorization form was 72.56, maternal summary sheet was 86.16, newborn summary sheet was 86.16, summary of labor and delivery was 47.18, delivery record was 76.85, labor record was 11.11. With respect to persons who recorded as a whole, the completeness data in doctors part were low, but nurses and medical record librarians were good. The results obtained from the analysis by Chi-Square and Pearson Product Moment Correlation Coefficient at 0.05 significant level showed that: 1. The factors that correlated with the completeness data of outpatient, general inpatient and obstetric inpatient were: magazine ownership, the numbers of outpatients per doctor per day, sex, marital status, education and working year of head-master of Medical Record Department(M.R.D), the mean age of workers in M.R.D. and the ratio between income utilization rate for developing the hospital. 2. The factors that correlated only with the completeness data of outpatient, and general inpatient were: type of hospital, the organization of M.R.D., age of head-master of M.R.D., head- master trained and the mean working year of workers. 3. The factors that correlated only with the completeness data of general inpatient and obstetric inpatient were: the numbers of computers in M.R.D. and bed occupancy rate. 4. The factors that correlated only with the completeness data of general inpatient were: groups of medical services and length of stay per discharged-patient. From this study, the recommendations are: 1. Outpatient medical record forms should be improved to be easier. 2. Medical records should be auditted before analysis. 3. The related persons should be motivated to attend in medical records. 4. The results of investigation should be followed up and recorded in medical records. 5. Recording data in doctor s part need help but the doctor must sign in that part. 6. The computers in M.R.D. must be used. 7. The head-master of M.R.D. should get certificate in medical record science. 8. Before every training, the M.R.D. staffs need should be surveyed and after the training there should also be a followed up.

บรรณานุกรม :
Saray Ruangdej . (2536). The Completeness of Medical Record at Provincial Hospitals in Central Part of Thailand, Ministry of Public Health.
    กรุงเทพมหานคร : ฐานข้อมูลวิทยานิพนธ์ไทย.
Saray Ruangdej . 2536. "The Completeness of Medical Record at Provincial Hospitals in Central Part of Thailand, Ministry of Public Health".
    กรุงเทพมหานคร : ฐานข้อมูลวิทยานิพนธ์ไทย.
Saray Ruangdej . "The Completeness of Medical Record at Provincial Hospitals in Central Part of Thailand, Ministry of Public Health."
    กรุงเทพมหานคร : ฐานข้อมูลวิทยานิพนธ์ไทย, 2536. Print.
Saray Ruangdej . The Completeness of Medical Record at Provincial Hospitals in Central Part of Thailand, Ministry of Public Health. กรุงเทพมหานคร : ฐานข้อมูลวิทยานิพนธ์ไทย; 2536.