Developing a Minimum Data Set for Calcium Disorders and Osteoporosis Records

Diagnosis and treatment of calcium disorders (hypocalcemia and hypercalcemia) and osteoporosis as the most important metabolic bone disease, are of great importance in internal medicine and endocrine diseases. There is no checklist of patient records for diagnosis, treatment and follow up in Iranian and foreign resources. This study was designed to provide minimum data set for registration in patient medical records.
Subjects and

Using Iranian and foreign published literature, a preliminary data form was prepared and evaluated using Delphi technique. In first stage the opinions of 25 internal specialists and 25 endocrinologists who selected 75% or more as"high" for a data question were included as main element in record. In the second stage, elements selected as "high" or "middle" (50-75 %) were assessed by 10 endocrinologist and analyzed. Elements that had greater than or equal to 50% chose "high" were added to final checklist.

Selected elements presented as checklist, and minimum data set in 7 categories: demographic information, history, symptoms, signs, paraclinical data, treatment and follow-up for disease presented. The scores for osteoporosis was 158 out of 187, while hypocalcemia was 82 of 140 and hypercalcema was 85 of 158.

These final elements provide as an applied pattern for registration in patients’ medical records and contain the most important elements in the published literature