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Are structured data structured identically? Investigating the uniformity of pediatric patient data recorded using
R K Los1, J Roukema, A M van Ginneken
1Department of Medical Informatics, Room Ee2157, Erasmus MC, P.O. Box 1738, 3000 DR Rotterdam, The Netherlands. r.los@erasmusmc.nl
Methods of Information in Medicine
|January 10, 2006
Summary
Structured data entry using OpenSDE for patient records showed significant variation. Despite the application
Area of Science:
- Medical Informatics
- Clinical Data Management
Background:
- Structured data entry aims to improve data reliability and accuracy for clinical practice and research.
- OpenSDE is an application designed for structured recording of narrative patient data.
Purpose of the Study:
- To analyze the uniformity of data entered using the OpenSDE application.
- To gain insight into the consensus and discrepancies in recorded patient data.
Main Methods:
- Three pediatricians transcribed 20 paper patient records into OpenSDE.
- Recorded findings were systematically compared and categorized based on differences.
Main Results:
- Only 22% of findings were recorded identically across transcriptions.
- 17% of findings were recorded differently, often as free text.
- A substantial 61% of findings were omitted, inferred, or conflicted with the original paper record.
Conclusions:
- Structured data entry with OpenSDE does not inherently guarantee uniform data.
- Variability in data recording highlights challenges in achieving consistent structured patient data.
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Key Attributes include the following:
01:17Flow Sheet
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Graphic Sheet Documentation:
Here's a closer look at the examples of flowsheets commonly used by nurses:
Graphic Sheet Documentation:
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