Systematic Design of the Minimum Data Set Storage: An Essential Need to Create Purposed for Archiving

• Published in: Anfurmātīk-i salāmat va zīst/pizishkī Vol. 1; no. 2; pp. 113 - 121
• Main Authors: Majid Jangi, AmirAbbas Azizi, Mostafa Kamali Yousef Abad, Seyed Mahmood Tara
• Format: Journal Article
• Language: Persian
• Published: Kerman University of Medical Sciences 01.03.2015
• Subjects: information indexing; medical records; minimum archive data set
• ISSN: 2423-3870

Introduction: Medical records are considered as an essential element of patient’s health care provision. Due to a rising service provision by healthcare centers, there is an increase in the medical record loads as well. It has led to a series of problems‌, such as limited physical space, records wearing and an increased need for resources. Moreover, the most important efficiency of records, which is their application in clinical research, is questioned. In the present study, researchers have presented a model of minimum data sets which helps to index and electronically archive hard-copy records according to the selected data and metadata. Method: This study was an applied research type, conducted in three stages in 2013 via modified Delphi technique. Target population consisted of specialists working in hospitals. As the sample, 8 physicians who were specialists or subspecialists participated in interviews and filled out checklist surveys. The collected data were later analyzed using Excel 2013. Results: The results show that data elements such as “final diagnosis” and “operations and others” were the most common items considered by the physicians in clinical follow up, and most common medical records was “operation’s repots” . Finding significant correlation among physician’s research questions was not possible due to large variety of subjects. Conclusion: The researchers presented a framework of minimum data sets for a purposive archiving of records for clinical and research-based applications. This framework can act as the applied goal setting of the retrieval model based on physicians’ clinical requirements in their medical follow-ups. Furthermore, considering physicians’ needs for accessing records through analyzing their probable requests can provide a possibility of data retrieval in diverse conditions.