ISSN: 1300-0292
İndekslendiği Dizinler: SCIENCE CITATION INDEX EXPANDED
CINAHL, Index Copernicus,
Chemical Abstracts (CA),
Excerpta Medica / EMBASE
Dil: Türkçe, İngilizce
İçerik: Orijinal Araştırma, Derleme, Editöre Mektup, Olgu Sunumu, Tıp Eğitimi, Tıbbi Kitap İncelemeleri
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ORIGINAL RESEARCH ARTICLES |
Determination Of Occupation And Other Factors That May Have An Impact On Diagnosis And Treatment In Medical Records
Dr. Tevfik PINAR, a Dr. Z. Aytül ÇAKMAK, a Dr. Meral SAYGUN, a Dr. Nuriye ULUa
aHalk Sağlığı ABD, Kırıkkale Üniversitesi Tıp Fakültesi, KIRIKKALE
Objective: Industrialisation increased the impact of occupation on health. Accurate diagnosis and treatment requires detailed medical and occupational history. Material and Methods: The study has been performed in 19 different departments of Kırıkkale University Hospital. A total of 950 patients’ charts were retrospectively reviewed for accuracy of medical records whether they contain knowledge about occupation, environment and nutritional status as well as other important factors. Results: Only 34.7% of the necessary parameters were recorded in the medical charts, remaining 65.3% of the parameters were not recorded. Regarding the occupational history, 10.3% of the patients’ jobs were properly recorded, 2.4% of the charts contained length of work and 2.5% had the information of previous jobs. Environmental hazards exposures were reported in 3.9% and nutritional status in 7.5%. These parameters are the least recorded in the charts. Conclusion: Our study showed that medical charts have insufficent medical knowledge. Occupational, environmental and nutritional status were seldom questioned and recorded that may lead improper diagnosis and treatments.Keywords: Medical records; occupations; environmentTurkiye Klinikleri J Med Sci 2008, 28:40-47
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