Affiliation:
1. MSc of Health Information Technology, Vice Chancellor for Treatment Affairs Zahedan University of Medical Sciences Zahedan Iran
2. Department of Health Information Sciences, Faculty of Management and Medical Information Sciences Kerman University of Medical Sciences Kerman Iran
3. Department of Health Information Technology, Ferdows School of Health and Allied Medical Sciences Birjand University of Medical Sciences Birjand Iran
4. Paramedical School Torbat Heydariyeh University of Medical Sciences Torbat Heydariyeh Iran
Abstract
AbstractBackground and AimIranian hospitals are provided with hospital information systems (HISs) from different vendors, which make it hardly possible to summarize laboratory data in an consistent manner. Therefore, there is a need to design a minimum data set of laboratory data that will define standard criteria and reduce potential medical errors. The purpose of this study was to design a minimum data set (MDS) of laboratory data for an electronic summary sheet to be used in the pediatric ward of Iranian hospitals.MethodsThis study consists of three phases. In the first phase, out of 3997 medical records from the pediatric ward, 604 summary sheets were chosen as sample. The laboratory data of these sheets were examined and the recorded tests were categorized. In the second phase, based on the types of diagnosis we developed a list of tests. Then we asked the physicians of the ward to select which ones should be documented for each patient's diagnosis. In the third phase, the tests that were reported in 21%–80% of the records, and were verified by the same percentage of physicians, were evaluated by the experts' panel.ResultsIn the first phase, 10,224 laboratory data were extracted. Of these, 144 data elements reported in more than 80% of the records, and more than 80% of experts approved them to be included in the MDS for patients' summary sheet. After data elements were investigated in the experts' panel, 292 items were chosen for the final list of the data set.ConclusionsThis MDS was designed such that, if implemented in hospital information systems, it could automatically enable registering data in the summary sheet when patient's diagnosis is registered.