Development of minimum data set for electronic documentation of progress note in the general intensive care unit

Publish Year: 1399
نوع سند: مقاله ژورنالی
زبان: English
View: 173

This Paper With 6 Page And PDF Format Ready To Download

  • Certificate
  • من نویسنده این مقاله هستم

استخراج به نرم افزارهای پژوهشی:

لینک ثابت به این Paper:

شناسه ملی سند علمی:

JR_IJIMI-9-1_013

تاریخ نمایه سازی: 30 مرداد 1401

Abstract:

Introduction: The minimum data set is a standard method for collecting key data elements, which will finally improve healthcare and quality of treatment services. Electronic documentation in the intensive care unit (ICU) has a significant effect on the quality of data. In addition, using structured data and standard formats can facilitate documentation of progress note data. Therefore, the aim of this study was to create a minimum data set for an effective design and implementation of electronic documentation of progress note in the ICU.Material and Methods: This is an applied qualitative study conducted in the general intensive care unit of Namazi hospital in Shiraz, which is the largest education and treatment center in Shiraz and the only referral hospital in Southern Iran. In this study, four stages were used for designing the minimum data sets of electronic progress note: ۱. Using English literature, ۲. Local expert review, ۳. Designing prototypes, and ۴. Conducting group sessions. Finally, data were analyzed using descriptive statistics through SPSS ۲۱ software.Results: The minimum data set for electronic documentation of progress note in the ICU included the two demographic and clinical sections. In addition, the clinical data were classified into ۱۱ major groups, each consisting of other items. Meanwhile, ۴۶.۸% (۶۶ out of ۱۴۱) of information items were obtained from reviewing the literature and ۵۳.۲% (۷۶ out of ۱۴۱) from interviews. In group sessions, ۹۹.۲۹% of information items were finalized by experts.Conclusion: It is essential to create a standard and structured minimum data set for the electronic design and implementation of progress note data. In such a case, accurate, thorough and timely electronic documentation in presenting instantaneous reports on the status of patients is effective in management and clinical decision-makings.

Authors

Elham Fallahnejad

MSc of Health Information Technology, Shiraz University of Medical Sciences, Shiraz, Iran

Fatemeh Niknam

PhD Student of Health Information Management, Shiraz University of Medical Sciences, Shiraz, Iran

Reza Nikandish Nobar

Associate Professor, Department of Anesthesiology, School of Medicine, Anesthesiology and Critical Care Research Center, Namazi Teaching Hospital, Shiraz University of Medical Sciences, Shiraz. Iran

Farid Zand

Professor, Department of Anesthesiology, School of Medicine, Anesthesiology and Critical Care Research Center, Namazi Teaching Hospital, Shiraz University of Medical Sciences, Shiraz. Iran

Roxana Sharifian

Associate Professor, Department of Management & Medical Information Sciences, Health Human Resources Research Center, School of Management & Information Sciences, Shiraz University of Medical Sciences, Shiraz, Iran