Background: Diagnosis and treatment of calcium disorders (hypocalcemia, hypercalcemia)
and osteoporosis as the most important metabolic bone disease, are of great importance in internal medicine and endocrine diseases. There is not 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.
Methods:Using Iranian and foreign published literature, a preliminary data form was prepared and evaluated using Delphi technique.
In first stage 25 internal specialists and 25 endocrinologists that 75% or more chose "high" for the question was included as main element in record. Data from 50% -75 selected "high" or "middle" for them entered second-stage checklist and assessed by 10 endocrinologist and analysis, an element that is greater than or equal to 50% chose "high" for them, added to final checklist.
Findings:Selected elements presented as checklist, and minimum data set in 7 sections: demographic information, history, symptoms, signs, paraclinical data, treatment and follow-up for disease presented.82 of 140 items in hypocalcemia, 85 of 158 in hypercalcemia patients and 158 of 187 items in osteoporosis scored required points.
Conclusion:Elements study which was provided as an applied pattern for registration in patient medical records contains the most important elements of published literatures.