Essential data elements for electronic cardiovascular medical record systems in Iran

Abstract

Introduction: Electronic medical records play an important role in the management of patients. In order to develop cardiovascular electronic medical record systems, determining minimum data set is necessary. This study aimed to determine the essential data elements for electronic cardiovascular medical record systems. Material and Methods: Medical records of patients with cardiovascular diseases and also the literature were reviewed to develop a questionnaire regarding the data elements. 87 cardiovascular specialists and residents as well as 50 nurses working in cardiovascular departments of hospitals affiliated with Iran University of Medical Sciences participated in the study. The data elements with at least 75% of agreement were considered essential for electronic medical records. Data were analyzed using descriptive statistics in SPSS software. Results: The essential data elements were classified in 29 classes including admission, death, patients’ main complaints, clinical signs, observations, medications, cardiac surgery, risk factors, laboratory and pathology results, consultation, resuscitation, anesthetic, electrocardiography, blood transfusion or blood products, rehabilitation measures, angiography/venography, exercise testing, endoscopy/colonoscopy, medical imaging, echocardiography, nursing interventions, allergies and side effects, therapeutic implantations, cardiac examinations, physical examinations, angina, referrals, social backgrounds and history. Totally, out of 276 data elements, 245 elements were identified as the essential data elements for electronic cardiovascular medical record systems. Conclusion: In this study, essential data elements were defined for electronic cardiovascular medical records. Identifying cardiovascular minimum data set will be an effective step towards integrating and improving the management of these patients' information.