Comparative Study of Quality Improvement in Internsâ History Taking by using a new medical history Form with Review of System Part and current one without this part

Abstract

Background: One of the most important steps in diagnosis and treatment of diseases is taking a good medical history. Current medical history form of Ministry of Health and Medical Education in our country doesn’t have Review of System part. In this research quantity and quality of Interns’ recording ROS in a new form including this part was studied. Methods: This is a Quasi-experimental study. In control group current medical history form without ROS part and in the cases group new proposed form including ROS part were used to take medical history by interns. Quantity and quality of ROS writing were evaluated by Infectious Disease residents and specialists. All data were compared by K2 and Fisher T test in SPSS 24 software. Results: In control group, 2% of interns had written ROS, all in incorrect place, with moderate quantity. In case group, ROS was written 100% in correct place, with quality of low, moderate, good, very good as 3%, 8%, 71% and 18% in order of frequency. Infectious disease residents’ and specialists’ satisfaction quality as low, moderate, good, very good were 8%, 14%, 72%, 6% and 7%, 15%, 71%, 7% in order with significant difference. (p <0.001) Conclusions: In conclusion we found significant relation between quality and quantity of recording data with using medical history form with ROS part by interns. It is proposed to change current form to a new one with ROS part.