Determining the frequency of reporting laboratory data in summary sheets of patients in a pediatric ward based on the classification of diagnoses in ICD-10

Abstract

Background: A summary of clinical findings and laboratory data is collected in patient summary sheets. The aim of this study was to determine the frequency of laboratory data reported in the summary sheets based on the classification of diagnoses in ICD-10. Methods: A descriptive-cross sectional study was performed on summary sheets of patients admitted to the pediatric ward from March 2015 to February 2016.The laboratory data of these sheets were extracted using a data collection form. Because of high number of data in each sheet and given that, depending on the diagnosis, the reported laboratory data were different, to simplify the presentation of the results the data were categorized based on patients’ diagnoses which were coded by ICD-10. Results: A total of 10224 laboratory data were extracted, which included 47 unique data elements. The highest number of laboratory data was related to hematology (N = 14) and the lowest number was related to urine and stool analysis (N = 6). Conclusions: Laboratory data are recorded in summary sheets in accordance with patient's diagnosis. Therefore, it is possible to process the existing summary sheets and extract the registration rules, then implement these rules in hospital information systems to generate electronic summary sheets.

Keywords

• Common data elements
• Laboratory data
• Clinical laboratory information systems
• Electronic health records
• Hospital information systems