Types of essential clinical data

There are four types of essential clinical data that should be captured in a patient’s health record in structured data (ie, data from drop-down menus/pick lists) rather than unstructured data (free-text). The four areas are:

  1. Allergies and adverse reactions
  2. Past medical history
  3. Reason for visit
  4. Reason for prescription.

While free-text information is important for providing a narrative or context, it is prone to ambiguity and difficult to search. It should be used in complement to structured data.

Other Toolkits

The Royal Australian College of General Practitioners acknowledges Aboriginal and Torres Strait Islander peoples as the Traditional Custodians of the land and sea in which we live and work, we recognise their continuing connection to land, sea and culture and pay our respects to Elders past, present and future.