Development and Evaluation of Electronic Medical Record Admission Module in Intensive Care Unit: A Case Study in Iran

Introduction: Electronic medical record leads to effective information management. One of the most important sections of electronic medical records is the patient admission module. The aim of this study was to develop and evaluate the patient admission module in Intensive Care Unit. Methods: This developmental-applied study was conducted in 2021 in 3 steps: 1. Determining the requirements, 2. Designing, developing, and implementing, and 3. Evaluating usability. In the first step, we did the literature review and asked for the expert panel’s opinion; in the second step, we used word, and Reactjs, Expressjs programming language, and Mongodb database and Windows server; in the third step, the USE standard questionnaire was used. Results: Module requirements were classified into two categories: functional and non- functional requirements. Functional requirements address software quality features, and non- functional requirements include general requirements, demographic information, and clinical information. Demographic information was classified into two main categories: patient’s demographic information and documented physician information. Clinical information (287 data elements) in 13 main categories included the past history, vital signs, nervous system, respiratory system, cardiovascular system, genitourinary system, gastrointestinal system, hematology, integumentary system, infectious, antimicrobial drugs, problem list, and plan. Also, the results of usability evaluation showed that 87% of the physicians agreed with the use of this module. Conclusion: Given the trend towards e-health in Iran, the use of electronic medical record admission module in intensive care units can have a significant impact on the complete collection of admission data.