Evaluation of Recorded Data for Patient History and Final Diagnosis in Brucellosis Patients in a Major Training Hospital, North-East Iran

Purpose: Patient history and final diagnosis information must be properly recorded and stored in the patient’s medical chart. The purpose of this study was to evaluate the information adequacy of the patient history forms as well as the concordance of the final diagnosis recorded in the medical records of patients with International Classification of Diseases (ICD) system. Methods: This cross-sectional study was performed with 201 hospital records of patients with a final diagnosis of brucellosis at Imam Reza Hospital in Mashhad, Iran between the years of 2013-2017. First, the adequacy of the patient history form was assessed. Then, the final diagnosis recorded by the physician in the patient's file was matched to the ICD code. Results: The results were as follows: Patient age and history of drug use in 96%, marital status in 17%, address of residence and occupation in 42%, 3% and 38% of the height and weight of patients respectively, education in only one patient, history recent travel 15% and animal contact status in 53% were recorded in patient history forms. In 166 cases (82%), the final diagnosis recorded by the physician complied with the full ICD code. Brucella arthritis and neurobrucellosis were the definitive diagnoses that had the highest number of unrecorded ICD II codes in the patient records. Conclusion: Due to incomplete and/or incorrect taking of patient history, appropriate educational and training methods for physicians in training hospitals should be implemented. Concerning the final diagnosis recorded in the patient's file, physicians also need to learn about ICD and the importance of detailed recording in the final diagnosis.