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Introduction: Discharge summaries (DSs) are among the most important tools for transferring information from hospital physicians to other physicians and play an important role in the continuity of care. Low quality and lack of information are the main problems of DSs, and evaluation of their quality from the physicians' perspective in Iran has rarely been done. This study aimed to evaluate the DSs' quality of content and completeness. Method: This descriptive cross-sectional study was performed on the DSs of Shafa Hospital in Kerman. A valid and reliable researcher-made questionnaire (α=0.97) was used. This questionnaire had three sections, including questions related to demographic information, evaluation of the quality of DSs (8 questions), and the degree of completeness of the DSs (8 questions). Results: Out of 110 physicians, 98 (89%) filled out questionnaires. Completeness, awareness, continuity of care, legibility, relevancy, length, consistency, organization, and physicians’ satisfaction were below the average (50%) throughout the hospital. The highest level of physicians' satisfaction with the quality of the content (79.27%) and completeness (77.73%) was attributed to electronic discharge summaries of the neurology department. Organization, legibility, and consistency, respectively, were identified as the best predictors of physicians' satisfaction with the quality of the DSs’ content. Conclusion: Policymakers should increase the quality of DSs by creating instructions, holding documentation training courses, increasing the supervision of senior physicians on interns and residents, and finally developing electronic automated DSs.

Introduction: Considering the importance of accurate documentation in psychiatric history and mental assessment and its effect on the current and future treatment among patients, this study aimed to determine data elements in the psychiatric history and mental assessment forms. Method: This is a descriptive-comparative study. Using psychiatric history and assessment forms, the required data were gathered in this study. Finally, all psychiatric history and mental assessment forms gathered from the selected countries including the United States (n=9), Australia (n=1), France (n=1), Iran (n=2) were assessed. After preparing the comparative tables, a comprehensive list of data elements related to the psychiatric history and assessment was provided. Using bottom up approach the extracted data elements were categorized. Results: In total, 58 data elements including demographic data, patient history, current symptoms of disease, evaluation of psychological states, suicide risk assessment, behavioral/emotional conditions, thinking process, drug abuse assessment, family safety/violence assessment, multi-axial diagnosis and treatment type/plan were extracted from psychiatric history and assessment forms. Conclusion: The present study provides a general view of important data elements considered for documentation in psychiatric history and assessment forms.

Introduction: The cancellation of a surgery operation not only imposed too much expenditure on the healthcare system, but also waste lots of energy and time of patient and health care provider. The aim of this study was to assess reasons of surgery cancellation, and to provide a comprehensive list of cancellation reasons to implement in hospital information system for improving documentation. Method: This study is an applied-descriptive study which was conducted in two parts. In first part, all medical records of hospitalized patients in Shafa educational hospital during 6 months period which had been assigned a cancellation code based on ICD-10, were assessed. The data were collected through a researcher-made checklist and have been analyzed using SPSS.V18 software. The second part was literature review which provided a list of surgery cancellation reasons. To retrieve the relevant papers PubMed and Google Scholar databases were searched. Finally the results of two parts of the study were combined and a comprehensive list of surgery cancellation reasons was developed. Results: Of 7529 surgical operation, 1229 operations (16.4%) were cancelled. Most of the cancelled surgical operations were related to inappropriate patient’s clinical condition before surgery. Extracted cancellation reasons were categorized into 8 groups. Totally a list of 54 reasons for cancellation was developed. Conclusion: Precise documentation of surgery cancellation reasons in each health care institution in order to determine the reasons and plan to prevent them is essential. Designing an information system with proper information content can support the above mentioned issues.