Minimal Data Sets for Electronic Medical Records in Hospital Settings

Introduction: A medical record is a dataset of a patient which enables his/her health protection in the present and the future, based on registered past events, their evaluation and planning. In other words, a medical record is a very important component of an efficient administration and planning of a patient’s health care, especially in hospital settings. Medical records must be standardized to accomplish everything mentioned above. Due to the large number of technologies, applications and standards, which are used in the processing of information in health care, standardization is very hard to achieve. Patients and methods: 1194 patients were hospitalized at the surgical ward during a period of five months. The data about the patients was entered in a database. In order to assess the minimal data set that is necessary to adequately analyze data in the future, a database was created with all relevant questions about the anamnesis, diagnostic tests and surgical procedures. Results: It is possible to analyze data about the most frequent diagnoses at a surgical department using collected data. It is possible to assume the prevalence of the diagnosis, complication rate, duration of symptoms, postoperative pain level and several other important attributes that are not available otherwise. Discussion and conclusion: The minimal data set included routinely in hospital medical records can provide more thorough analysis of patients diagnosis, therapy, diagnostic procedures, complication rate etc. This can improve the quality of service and provide important data for the hospital management that can be used in planning and hospital management.