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

Abstract


Background 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.
Objectives To determine how structured and coded data are being introduced for the recording of patient histories, the benefits observed where structuring and coding have been introduced and the risks encountered when structuring and coding are introduced.
Methods We will search the following databases for evidence of published and unpublished material: CINAHL; EMBASE; Google Scholar; IndMED; LILACS; MEDLINE;NIHR; Paklit and PsycINFO.We will, depending on the study designs employed, use the Cochrane EPOC, Joanna Briggs Institute (JBI) and Newcastle_Ottawa instruments to critically appraise studies. Data synthesis is likely to be undertaken using a narrative approach, although meta-analysis will also be undertaken if appropriate and if the data allow this.
Results This protocol should represent a reproducible approach to reviewing the literature regarding structuring and coding in patient histories. We anticipate that we will be able to report results in early 2011.
Conclusion The review should offer increased clarity and direction on the optimal balance between structuring/coding and free text recording of data relating to the patient history.

Keywords


clinical coding; electronic health records; patient history; structuring of records

Full Text:

PDF


DOI: http://dx.doi.org/10.14236/jhi.v18i3.772

Refbacks

  • There are currently no refbacks.


This is an open access journal, which means that all content is freely available without charge to the user or their institution. Users are allowed to read, download, copy, distribute, print, search, or link to the full texts of the articles in this journal starting from Volume 21 without asking prior permission from the publisher or the author. This is in accordance with the BOAI definition of open accessFor permission regarding papers published in previous volumes, please contact us.

Privacy statement: The names and email addresses entered in this journal site will be used exclusively for the stated purposes of this journal and will not be made available for any other purpose or to any other party.

Online ISSN 2058-4563 - Print ISSN 2058-4555. Published by BCS, The Chartered Institute for IT