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Education toolkits for general practice

High-quality health records

Types of essential clinical data

Last revised: 17 Jun 2020

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.

This event attracts CPD points and can be self recorded

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