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Abstract

This study presents a minimum dataset designed to complement manual health record documentation in Traditional Malay Medicine (TMM) postnatal care. TMM postnatal treatment is widely sought after by Malay mothers during their confinement period. However, TMM healthcare providers either still utilize paper based records or do not provide proper documentation during treatment. This leads to unavailability of continuity and seamless healthcare services for TMM patients, making it fragmented from modern medicine. This research shall attempt to propose a minimum dataset for postnatal care as a foundation to facilitate integration of modern medicine and Traditional Malay Medicine. Data collection was conducted to establish a minimum dataset using structured interviews for participants involved in the postnatal care process - doctors, nurses and TMM practitioners. A total of nineteen core and fourteen additional clinical indicators were established. The results of this study shall serve as a basis to establish electronic health record research areas in the TMM field such as clinical decision support systems and e-health systems.