Safdari R, Mahdavi S, Shahmoradi L, Adabi K, Tahmasebian S, Nazari M. Designing and Development of Electronic Health Records for Patients with Hydatidiform Mole and Evaluation of Completeness of Medical Records. payavard 2019; 12 (5) :359-366
URL:
http://payavard.tums.ac.ir/article-1-6632-en.html
1- Professor, Health Information Management Department, School of Allied Medical Sciences, Tehran University of Medical Sciences, Tehran, Iran
2- Master of Science in Health Information Technology, Health Information Management Department, School of Allied Medical Sciences, Tehran University of Medical Sciences, Tehran, Iran
3- Associate Professor, Health Information Management Department, School of Allied Medical Sciences, Tehran University of Medical Sciences, Tehran, Iran
4- Assistant Professor, Obstetrics and gynecology Department, Moheb Yas Hospital, Tehran University of Medical Sciences, Tehran, Iran
5- Assistant Professor in Medical Informatic, Medical Genetics Department, Shahrkord University of Medical Sciences, Shahrkord, Iran
6- Master of Science in Health Information Technology, Health Information Management Department, School of Allied Medical Sciences, Tehran University of Medical Sciences, Tehran, Iran , nazarimah68@yahoo.com
Abstract: (3828 Views)
Background and Aim: To provide effective care, health care providers need timely and appropriate information. Electronic records provide quick access and easy management of data. The aim of this study was to develop electronic health records for patients with hydatidiform mole and evaluation of completeness of medical records
Materials and Methods: This applied study was conducted in 2017. After verifying the minimum data set required for the system, data were extracted from patient records using a checklist and entered into SQL server. SQL server 2012 and Visual Studio 2013 to design electronic records and SPSS 20 for data analysis was used. Extent of data completion in patient records was also assesed.
Results: Data on the completion of paper records indicated that in 100% of cases, “address” item was filled in. The less completed data was related to carotene deficiency (%1.1). Our findings also showed that the eight most important items like age of first menstruation, first gestational age, interval between pregnancies, number of sexual partners, menstruation between pregnancies, contraceptive methods, social habits and radiotherapy, were not completed in all records.
Conclusion: Many of the important minimum data set for hydatidiform mole disease were either not completed or completed in limited numbers in paper records. By developing such health records, we can ensure better prevention and treatment, and regular follow-up for the patients and help them to save their time and costs.
Type of Study:
Original Research |
Subject:
Health Information Technology ePublished: 1399/07/23