Development and Evaluation of Electronic Medical Record Admission Module in Intensive Care Unit: A Case Study in Iran

Electronic medical record leads to effective information management. One ofthe most important sections of electronic medical records is the patient admission module.The aim of this study was to develop and evaluate the patient admission module in IntensiveCare Unit. This developmental-applied study was conducted in 2021 in 3 steps: 1. Determiningthe requirements, 2. Designing, developing, and implementing, and 3. Evaluating usability.In the first step, we did the literature review and asked for the expert panel’s opinion; in thesecond step, we used word, and Reactjs, Expressjs programming language, and Mongodbdatabase and Windows server; in the third step, the USE standard questionnaire was used. Module requirements were classified into two categories: functional and nonfunctionalrequirements. Functional requirements address software quality features, and nonfunctionalrequirements include general requirements, demographic information, and clinicalinformation. Demographic information was classified into two main categories: patient’sdemographic information and documented physician information. Clinical information (287data elements) in 13 main categories included the past history, vital signs, nervous system,respiratory system, cardiovascular system, genitourinary system, gastrointestinal system,hematology, integumentary system, infectious, antimicrobial drugs, problem list, and plan.Also, the results of usability evaluation showed that 87% of the physicians agreed with theuse of this module. Given the trend towards e-health in Iran, the use of electronic medical recordadmission module in intensive care units can have a significant impact on the completecollection of admission data.