[Data requirement and appropriated structure for diabetes progress note]

ABSTRACT

Introduction: Currently, the world faces the serious problem of chronic diseases. These diseases need on going care more than treatment. For care to be recognized as a principle, it should be standard, recordable and evaluable. This requires specific data to beenteredin a system with the appropriate framework. This study aims to determine data requirements and appropriate structure for a template that documents diabetes. Materials and Methods: This was a descriptive cross-sectional study performed in 2013-2014. A checklist containing 18 groups of diabetes data elements was prepared through studying the inpatient and outpatient diabetes records, as well as related research studies. The check list was presented to and evaluated by a focus group consisting 8 experts. An score was calculated for each of the data elements according to the item influence index formula. Results: Using the item influence index formula, of a total of 99 data elements, 73 were approved and 26 were rejected. Data were classified based on the Subjective, Objective, Assessment, Plan [SOAP] method. Conclusion: As the approved data requirements were derived from a focus group containing endocrinologists, health information management and medical informatics experts, and classified based on the standards of SOAP, it is expected that the approved data and structure be an appropriate tool for diabetes data collection and acceptable to its users