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:
- Allergies and adverse reactions
- Past medical history
- Reason for visit
- 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.