• Logo
  • HamaraJournals

Development of Minimum Data Set for Electronic Documentation of Progress Note in the General Intensive Care Unit

Elham Fallahnejad, Fatemeh Niknam, Reza Nikandish Nobar, Farid Zand, Roxana Sharifian



Introduction: Electronic documentation in the intensive care unit (ICU) has a significant effect on the quality of data. In addition, using structured data and standard formats can facilitate documentation of progress note data. Therefore, the aim of this study was to create a minimum data set for an effective design and implementation of electronic documentation of progress note in the ICU.

Material and Methods: This is an applied qualitative study conducted in the general intensive care unit of Namazi Hospital in Shiraz, which is the largest education and treatment center in Shiraz and the only referral hospital in Southern Iran. In this study, four stages were used for designing the minimum data sets of electronic progress note: 1. Using English literature, 2. Local expert review, 3. Designing prototypes, and 4. Conducting group sessions. Finally, at the quantitative stage of the study, the data were analyzed using descriptive statistics (frequency and percentage) through SPSS 21 software.

Results: The minimum data set for electronic documentation of progress note in the ICU included the two demographic and clinical sections. In addition, the clinical data were classified into 11 major groups, each consisting of other items. Meanwhile, 46.8% (66 out of 141) of information items were obtained from reviewing the literature and 53.2% (76 out of 141) from interviews. In group sessions, 99.29% of information items were finalized by experts.

Conclusion: it is essential to create a standard and structured minimum data set for the electronic design and implementation of progress note data. In such a case, accurate, thorough and timely electronic documentation in presenting instantaneous reports on the status of patients is effective in management and clinical decision-makings.


Pickering BW, Dong Y, Ahmed A, Giri J, Kilickaya O, Gupta A, et al. The implementation of clinician designed, human-centered electronic medical record viewer in the intensive care unit: A pilot step-wedge cluster randomized trial. Int J Med Inform. 2015; 84(5): 299-307. PMID: 25683227 DOI: 10.1016/j.ijmedinf.2015.01.017

Bosman R. Impact of computerized information systems on workload in operating room and intensive care unit. Best Pract Res Clin Anaesthesiol. 2009; 23(1): 15-26. PMID: 19449613 DOI: 10.1016/j.bpa.2008.10.001

Bosman R, Rood E, Oudemans-van Straaten H, Van der Spoel J, Wester J, Zandstra D. Intensive care information system reduces documentation time of the nurses after cardiothoracic surgery. Intensive Care Med. 2003; 29(1): 83-90. PMID: 12528027 DOI: 10.1007/s00134-002-1542-9

Carayon P, Wetterneck TB, Alyousef B, Brown RL, Cartmill RS, McGuire K, et al. Impact of electronic health record technology on the work and workflow of physicians in the intensive care unit. Int J Med Inform. 2015; 84(8): 578-94. PMID: 25910685 DOI: 10.1016/j.ijmedinf.2015.04.002

Ehteshami A, Sadoughi F, Ahmadi M, Kashefi P. Intensive care information system impacts. Acta Inform Med. 2013; 21(3): 185-91. PMID: 24167389 DOI: 10.5455/aim.2013.21.185-191

De Georgia MA, Kaffashi F, Jacono FJ, Loparo KA. Information technology in critical care: Review of monitoring and data acquisition systems for patient care and research. Scientific World Journal. 2015; 2015: 727694. PMID: 25734185 DOI: 10.1155/2015/727694

Daphtary K. Computerized clinical documentation in the pediatric intensive care unit : Quality of notes and factors that affect the quality [Master Thesis]. Oregon Health & Science University; 2014.

Schiff GD, Bates DW. Can electronic clinical documentation help prevent diagnostic errors? N Engl J Med. 2010; 362(12): 1066-9. PMID: 20335582 DOI: 10.1056/NEJMp0911734

Brown PJ, Marquard JL, Amster B, Romoser M, Friderici J, Goff S, et al. What do physicians read (and ignore) in electronic progress notes? Appl Clin Inform. 2014; 5(2): 430-44. PMID: 25024759 DOI: 10.4338/ACI-2014-01-RA-0003

Leigh JP, Kamran H, Dodek PM, Bagshaw SM, Forster AJ, Turgeon AF, et al. Textual analysis of physician progress notes for patients transferred from the intensive care unit to hospital ward. American Journal of Respiratory and Critical Care Medicine. 2017; 195: A7084.

Sadoughi F, Nasiri S, Langarizadeh M. Necessity for designing national minimum data set of perinatal period in Iran: A review article. Medical Journal of Mashhad University of Medical Sciences. 2014; 57(5): 727-37.

Sadoughi F, Shahi M, Ahmadi M, Davaridolatabadi N. The comparison of the minimum data set for elderly health in selected countries. Acta Inform Med. 2015; 23(6): 393–7. PMID: 26862252 DOI: 10.5455/aim.2015.23.393-397

Embi PJ, Yackel TR, Logan JR, Bowen JL, Cooney TG, Gorman PN. Impacts of computerized physician documentation in a teaching hospital: Perceptions of faculty and resident physicians. J Am Med Inform Assoc. 2004; 11(4): 300-9. PMID: 15064287 DOI: 10.1197/jamia.M1525

Karimi S, Saghaeian Nejad Isfahani S, Farzandipour M, Esmaeili Ghayoumabadi M. Comparative study of minimum data sets of health information management of organ transplantation in selected countries and presenting appropriate solution for Iran. Health Information Management. 2011; 7: 497-505.

Jahanbakhsh M, Moghaddasi H, Hosseini A. Designing of diabetic mellitus minimum data sets: Indicator basis of diabetic management effectiveness. Health Information Management. 2010;7(3): 330-40.

van de Klundert N, Holman R, Dongelmans DA, de Keizer NF. Data resource profile: The Dutch national intensive care evaluation (NICE) registry of admissions to adult intensive care units. Int J Epidemiol. 2015; 44(6): 1850-1850h. PMID: 26613713 DOI: 10.1093/ije/dyv291

Australian and New Zealand Intensive Care Society. Adult patient database (APD): Data dictionary for software programmers [Internet]. 2013 [cited: 1 Jun 2020]. Available from: https://www.anzics.com.au/adult-patient-database-apd/

Southwest Texas Medical Associates. Hospital daily progress note tutorial [Internet]. 2007 [cited: 1 Jun 2020]. Available from: http://www.setma.com/EPM-Tools/tutorial-daily-progress-note.

Kalankesh LR, Dastgiri S, Rafeey M, Rasouli N, Vahedi L. Minimum data set for cystic fibrosis registry: A case study in Iran. Acta Inform Med. 2015; 23(1): 18–21. PMID: 25870486 doi: 10.5455/aim.2015.23.18-21

Sheikh S, Zemel BS, Stallings VA, Rubenstein RC, Kelly A. Body composition and pulmonary function in cystic fibrosis. Front Pediatr. 2014; 2: 33. PMID: 24783186 DOI: 10.3389/fped.2014.00033

Mahmoudvand Z, Kamkar M, Shahmoradi L, Nejad AF. Determination of minimum data set (MSD) in echocardiography reporting system to exchange with Iran’s electronic health record (EHR) system. Acta Inform Med. 2016; 24(2): 116-9. PMID: 27147803 DOI: 10.5455/aim.2016.24.116-119

DOI: http://dx.doi.org/10.30699/fhi.v9i1.226


  • There are currently no refbacks.