[Standardization of data elements of audiology records: a suitable model for Iran]

ABSTRACT

Providing high quality health care is not possible without information related to the past and current condition of the patient. Records show which services, where, when and by whom was delivered. Documentation is referred to the process of precisely recording the information regarding patient care and treatment. The purpose of this study is to determine the essential data set required in audiology record keeping and designing a model for Iran. In an applied research of a descriptive-comparative type which was carried out in 2010, data elements of audiology records of domestic and foreign patient notes were used to compile a check list which was subjected to debate by Iranian audiologists in Delphi method. 110 audiologists and 17 faculty members responded to the opinion poll. From 51 elements which were subjected to discussion, 37 elements by more than 75 percent of the participants, nine elements by 50 to 75 percent of the participants and five elements by less than 50 percent of the participants, were agreed upon. The only element to be considered more important by faculty members than audiologists was "Gender" [p=0.018]. Seventy percent of the participants valued the effectiveness of information in patient records very high. The minimum data set for audiology records must include demographic information, past medical history, patient assessment and treatment plan. With reference to record design principles this information was used to develop a model for patient audiology record which also included the necessary instructions for completing it