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Table 2 Participants’ perspective about the necessity of recording and communicating complementary data to SEPAS

From: Evaluating the demographic and clinical minimum data sets of Iranian National Electronic Health Record

  Survey > 50% participants identified as mandatory Survey > 50% participants identified as optional Survey > 50% participants identified as unnecessary
Demographic data Patient unit number
Nickname
Age
Province
City
Driver’s license number
Military status
Religion
Denominations
Ethnicity
Dialect
Spouse personal details
Death certificate number
the deceased person’s full address
Delivery and childbirth Type of delivery
Cause of delivery
Delivery location
Number of newborns
Birth order
Newborn weight
Newborn Health status
Congenital anomalies
Newborn unit number
Patient examinations Main complaints
Primary diagnosis
Diagnosis during treatment
Physician orders
Physical examination and clinical investigation
Nurse observations
Underlying disease
Family history
Vital signs Systolic blood pressure
Diastolic blood pressure
Heart rate
Respiratory rate
Temperature
Operations Operation name
Type of operation (outpatient, inpatient)
Date of operation
Anesthesia Allergies Type of anesthesia
Anesthetics
Anesthesia time
Type of allergy
Allergens
Severity of allergy diagnosis
Date identify allergies
Specific patient conditions Pregnancy or breastfeeding
Alcohol consumption
Smoking
Tobacco usage
Prosthesis in patient body
Diet
Medications Medication name
Medication type (Therapeutic)
Medication form
Medication dose
Medication usage
Patient medication history
Drug sensitivity
Blood type Blood group
Rh