The Effect of Feedback and Incentive Mechanisms on Improving Residents’ Medical Record Documentation Procedure

Introduction: Studies indicate that using behavior changing interventions may improve medical record documentation. This study aimed to examine the effect of feedback and incentive mechanisms on medical record documentation among surgery residents in Kashan University of Medical Sciences. Methods: This quasi-experimental study examined the effect of feedback and incentive mechanisms on 19 surgery residents’ medical record documentation in Kashan Shahid Beheshti Hospital in 2013-14. During three phases of pre-intervention, post-intervention and 3 months after intervention, five medical records for each resident (total=95) were selected and assessed using a checklist. Data were analyzed by means of t-test and Wilcoxon test. Results: There were significant changes in surgical residents’ medical record documentation during pre- intervention, post-intervention three months after intervention (P=0.0001). Findings showed that the rate of documentation in medical history form, course of disease, reception and discharge summary, and surgery report had significant changes after the interventions (P= 0.0001). Conclusion: Since the results showed that feedback and incentive mechanisms had positive impacts on improving residents’ documentation behavior, it is suggested that residents’ documentation performance should be regularly assessed and feedbacks be provided for other residents and stakeholders.