The benefits and risks of structuring and coding of patient histories in the electronic clinical record: protocol for a systematic review

Emma Byrne, Bernard Fernando, Dipak Kalra, Aziz Sheikh

Research output: Contribution to journalArticlepeer-review

Abstract

Data in medical records have in part been recorded in structured and coded forms for some decades. However, the patient history is as yet largely recorded in an uncoded format. There is a need to consider the optimal balance of use of free text and coded data in the patient history. This review protocol summarises our plans to identify, critically appraise and synthesise evidence relating to approaches taken to introduce structure and coding within patient histories in electronic health records, and the empirically demonstrated benefits and risks of structuring and coding of patient histories in health records.
Original languageEnglish
Pages (from-to)197-203
Number of pages7
JournalInformatics in Primary Care
Volume18
Issue number3
DOIs
Publication statusPublished - 2010

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