Investigating the Status of Registration of the Main Complaint and the Faults and Written and Structural Errors of the Main Complaint

Abstract

Introduction: Registration of main complaint  is one of the most significant part of medical education and recording. The current study was designed to examine the main complaint registration status and the mistakes and written and structural errors of the main complaint in the files of the internal ward to review and identify existing problems.

Methods: In the present study, the records of 150 externs, 150 interns, and 150 residents (assistants) of different sections of the internal ward were randomly selected and a sheet containing the main complaint and a description of the current disease was copied and files are reviewed based on a questionnaire designed with different characteristics of the main complaint.

Results: In the features examined in the questionnaire for the key complaint recorded in the internal ward files: 1-Consistency and coordination between the current disease record and the main complaint: the highest rate was in the group of residents with 90%, then interns with 79% and the externs with 97 were the lowest. 2. Stating the reason for the main complaint: interns 89, residents 80% and externs 60%. 3. The correct way of “phrasing” the main complaint: residents 99%, interns 90% and externs 80%. 4. Using iatrotropic stimulus: residents 41%, interns 33% and externs 23%. 5. Student Status: None of the students commented on their backgrounds. 6. Lack of using medical terms: Residents with 29% were the lowest and externs with 43% were the highest.

Conclusion: In the reviewed files, the highest number of error was in the feature of checking the student's position and not commenting on the student's record and then in using the iatrotropic stimulus and the least amount of errors was in the feature of writing a phrase.