Determination of occupation and other factors that may have an impact on diagnosis and treatment in medical records

Abstract

Objective: Industrialisation increased the impact of occupation on health. Accurate diagnosis and treatment requires detailed medical and occupational history. Material and Methods: The study has been performed in 19 different departments of Kirikkale University Hospital. A total of 950 patients' charts were retrospectively reviewed for accuracy of medical records whether they contain knowledge about occupation, environment and nutritional status as well as other important factors. Results: Only 34.7% of the necessary parameters were recorded in the medical charts, remaining 65.3% of the parameters were not recorded. Regarding the occupational history, 10.3% of the patients' jobs were properly recorded, 2.4% of the charts contained length of work and 2.5% had the information of previous jobs. Environmental hazards exposures were reported in 3.9% and nutritional status in 7.5%. These parameters are the least recorded in the charts. Conclusion: Our study showed that medical charts have insufficent medical knowledge. Occupational, environmental and nutritional status were seldom questioned and recorded that may lead improper diagnosis and treatments.