Abstract
Medical records serve as a tool for the continuation of patient care, maintaining communication among health team members, providing quality assurance and, at present, using them as a reference for allocation of budgets under the national universal healthcare coverage scheme (UC). This study was aimed at exploring the level of quality of the medical records and developing good-quality procedures for in-patient records through multidisciplinary participation at Muangsruang Hospital. A descriptive study was used, with both qualitative and quantitative methods: in-depth interviews were conducted with doctors, nurses, anesthetic nurses, pharmacists and medical information technicians. Additionally, focus groups were set up with two groups of nurses. Moreover, 50 medical records were randomly sampled and were thoroughly examined. Data were analyzed using several methods, including content analysis, and triangulation techniques. Twentyfour staff members were interviewed and eight nurses joined each focus group. All professional groups realized that medical records are very important. Physicians, nurses and anesthetic nurses had clear guidelines on recording procedures. The recording quality was classified as good in 80.91 percent of the records. The accuracy of the medical records on the diagnoses of physicians and on codifications for diagnoses with procedures were 58 and 56 percent, respectively. The quality of medical records was influenced mainly by a number of factors, including clear policy deployment from executive officers, awareness among stakeholders, appropriate format of the forms, involvement of stakeholders in developing criteria for practical recording, the monitoring and evaluating systems used, the arrangement of a conference related to nursing care records, the availability of technical articles related to pharmaceutical care and nursing care at the ward as references.
