Summary
Objective: To define a core dataset for preoperative assessment to leverage uniform data collection
in this domain. This uniformity is a prerequisite for data exchange between care providers
and semantic interoperability between health record systems.
Methods: To design this core dataset a combination of literature review and expert consensus
meetings were used. In the first meeting a working definition for “core dataset” was
specified. Subgroups were formed to address major headings of the core dataset. In
the following eight meetings data items for each subheading were discussed. The items
in the resulting draft of the dataset were compared to those retrieved from an earlier
literature review study. In the last two expert meetings modifications of the dataset
were performed based on the result of this literature study.
Results: Based on expert consensus a draft dataset including 82 data items was designed. Seventy-six
percent of data items in the draft dataset were covered by the literature study. Nine
data items were modified in the draft and 14 data items were added to the dataset
based on input from the literature review. The final dataset of 93 data items covers
patient history, physical examination, supplementary examination and consultation,
and final judgment.
Conclusions: This preoperative-assessment dataset was defined based on expert consensus and literature
review. Both methods proved to be valuable and complementary. This dataset opens the
door for creating standardized approaches in data collection in the preoperative assessment
field which will facilitate interoperability between different electronic health records
and different users.
Keywords
Preoperative care - dataset - hospital information systems - core dataset - database
