Determining the Minimum Data Set for Uveitis Patients’ Electronic Health Records in Iran

Abstract

Background and Aim: The quality of Electronic Health Records (EHRs) depends on the quality of its content and proper documentation. Determining the Minimum Data Set (MDS) to enhance the quality of electronic health records’ content and helping to improve the quality of health care provision to uveitis patients are essential matters. The aim of this study is to determine the essential MDS for uveitis patients’ electronic health records. Materials and Methods: In this descriptive-analytical study, data collection tools for collecting the Minimum Data Set were library resources and internet-based database. The MDS was obtained through Likert scale questionnaire and was surveyed by 22 ophthalmologists and retina subspecialists. Results: Among the elements of the survey, all cases with over 90% approval were considered as main elements. Regarding the importance of presented data elements, no significant difference was found between the responses of ophthalmologists who participated in this study. Conclusion: The Minimum Data Set of uveitis patients’ electronic health records can be represented by five groups of demographic information: patients’ clinical records, laboratory information, type of uveitis, treatment guidelines, and the information of ophthalmic pictures. A suggested model for manual systems and electronic medical records is available.

Keywords

• minimum data set (mds)
• data elements
• documentation
• health records
• uveitis disease