Medical records include information about the status and the hospital course of a patient and the instructions given to the patient. The accurate, accessible and up to date information can be used for further evaluation of the patient and also probable research projects.

Qualitative study of the archived patients’ files.

Evaluating the quality of the medical records at the psychiatric ward.

The study was an observational descriptive study in which 400 archived files at the psychiatric ward of Imam Hossein Hospital during the years of 2007 and 2008 were qualitatively studied. The data was gathered by a data sheet and was analyzed using SPSS v. 15.0.

Among patient's demographic information, place of birth was not recorded in 82% of the files followed by birth date that was missing in 38% of the files. Case history, psychiatric formulations and progressive notes of patients were not appropriately recorded in 2.5% of the patients’ files. Finally, the summary sheets did not clarify the main complaint in 11.7% of the files and 7.5% of them lacked information to indicate dates of admission and discharge. Only 21.25% of the summaries defined initial and final diagnosis.

With regards to the results and since there were incomplete data; the information could not be properly used as the raw material for researches. It seems that more supervision is needed to completely fill the files.