electronic documentation

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 aimof this study was to create a minimum data set for an effective design and implementation of electronic documentation of progress note in the ICU.

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: 1. Using Englishliterature, 2. Local expert review, 3. Designing prototypes, and 4. Conducting group sessions. Finally, data were analyzed using descriptive statistics through SPSS 21 software.

The minimum data set for electronic documentation of progress notein the ICU included the two demographic and clinical sections. In addition, the clinical data were classified into 11 major groups, each consisting of other items. Meanwhile, 46.8% (66 out of 141) of information items were obtained from reviewing the literature and 53.2% (76 out of 141) from interviews. In group sessions, 99.29% of information items were finalized by experts.

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.