Background and Aim: In order to better design an electronic health record system in the
country, determining standardized data elements for creating an integrated
information system is important. In this study, the minimum data set of
radiology reporting system is determined.
Materials and Methods: In this descriptive cross-sectional study, 13 radiologists, 3
anesthesiologists, 3 general practitioners and 3 insurance experts working in
the Imaging Center of Imam Khomeini hospital in Tehran were chosen. The
research tool was a questionnaire having 11 parts. Content validity and
test-retest method were used to measure the validity and reliability of the
questionnaire, respectively. Data analysis was performed using the SPSS
software.
Results: The highest means
reported were radiologists' written explanations and suggestions (9.6), image
interpretation (9.5), the name of contrast material (9.4), the name of imaging
procedure (9.3) type and date of previous measures (9.1), and the final
diagnosis (9) and the lowest averages belonged to referring physician's
address (4.8), relationship between patients and the primary individual insured
(4.3), and religion (2.2).
Conclusion: In an electronic health record system, due to
the importance of radiology reports for the diagnosis and future management of
a patient's clinical problems, it is necessary to pay attention to the minimum
set of data related to these reports such as administrative, insurance, patient
identity, and clinical data, and the results of radiological examinations for exchanging
with electronic health record system.
