Education toolkits for general practice
High-quality health records
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:
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.
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