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.