Electronic Medical Records for Mental Disorders: What Data Elements Should These Systems Contain?

Identifying data elements of electronic medical record systems (EMRs) is one of the essential steps for the comprehensive and proper health data collection. The aim of this study was to determine the data elements required for EMRs in the field of mental disorders. We conducted a literature review and also we randomly selected 50 medical records of patients with mental disorders to identify a preliminary list of essential data elements for EMRs for mental disorders. Then, 33 mental health specialists were surveyed to validate the list of data elements through a questionnaire. We identified that health data elements of EMRs for patients with mental disorders can be categorized into seven classes (demographic data of patients, administrative data of physicians, administrative data of patients, history, clinical data, treatment, and financial data) and 10 subclasses. After the validation process, 140 essential data elements for EMRs for patients with mental disorders were introduced.