Abstract

Introduction: Healthcare providers’ awareness of laws governing medical documents and patients’ health-related information is essential in securing the patients’ rights. Given the existing legal problems in documentation of medical record of Consent and Acquittal, we decided to perform an investigation examining the levels of ophthalmologists’ awareness of legal requirements for medical record of consent and acquittal and how they complied with such requirements at Feiz Teaching Hospital, Isfahan in the year 2011. Methodology: This research is an applied, descriptive-analytic one. The research population for awareness measurement includes attending ophthalmologists at Feiz Hospital. Filled-in consent record forms recorded in medical document were used to examine the levels of compliance with legal requirements governing medical record of consent and acquittal. Sampling among the attending ophthalmologists was performed using consensus which included 14 ophthalmologists. The files were samples using the statistical formula, resulting in a sample of 303 files. Data collection tools included a questionnaire and a check list. The questionnaire’s reliability was estimated through Cronbach’s alpha calculation (0.8); and the check list was completed through a survey among professors of Health Information Technology Management department. In a first step, investigators handed a questionnaire containing 12 items to the ophthalmologists in order to assess their levels of awareness from legal Aspects of medical Informed consent and acquittal, and received the completed questionnaire after answering their possible queries on the issue. In the next step the researchers went to the hospital and evaluated the levels of compliance with legal aspects of medical informed consent and acquittal within the files using a check list and by direct observation. Analytic statistics and SPSS software were used to analyze the data; and Pearson test was applied to evaluate the assumed relationship. The findings were descriptively analyzed, results of which are presented in scored tables (scores 0-50: undesirable; 51-81: relatively desirable; 81 and above: desirable). Results: The ophthalmologists’ level of awareness from legal aspects of informed consent and acquittal was 78.72% and their level of compliance with these requirements was 53.17%. There was a weak and reverse correlation between awareness and compliance (r= -0/187, P-value= 0/001). Conclusion: There is a significant association between the ophthalmologists’ levels of awareness from legal aspects for obtaining informed consent and acquittal and the levels of their compliance with such requirements as seen in completed record of consent and acquittal; but there is low correlation between them.

Key words: Awareness, informed consent, law, medical record of acquittal, teaching hospital.