Nursing minimum data set in the multidisciplinary electronic health record.
The development of an electronic health record requires consensus about its structure and content. The structure and content of the electronic health record refers to the standardization of views, main headings and subheadings. Views are subrecords of electronic health records that are comprised of specific data elements. Agreement on the unified structure of the electronic health record was reached by means of the consensus-based Delphi method and nominal group meetings. The structure includes general views, views by specialists, views by services, views by preventive health care and views by different health care professionals. The main headings are admission, planning, delivery and outcomes of care. In addition, there are 28 subheadings. The first experiences of the applicability of the structure will be obtained after it has been implemented in electronic health record systems by 2007. The goal is through the unified structure of electronic health records to facilitate the transfer of data between health care providers and to maintain the quality of care.
Häyrinen
Kristiina
K
Department of Health Policy and Management, University of Kuopio, Finland. kristiina.hayrinen@uku.fi
Saranto
Kaija
K
D032921:Consensus; D003697:Delphi Technique; D005387:Finland; D006801:Humans; D033183:Interdisciplinary Communication; D016347:Medical Records Systems, Computerized / Q000592:standards*; D009732:Nursing Care