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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
Objective:
OpenSDE is an application that supports structured recording of narrative patient data to enable use of the data in both clinical practice and clinical research. Reliability and accuracy of collected data are essential for subsequent data use. In this study we analyze the uniformity of data entered with OpenSDE. Our objective is to obtain insight into the consensus and differences of recorded data.
Methods:
Three pediatricians transcribed 20 paper patient records using OpenSDE. The transcribed records were compared and all recorded findings were classified into one of six categories of difference.
Results:
Of all findings 22% were recorded identically; 17% of the findings were recorded differently (predominantly as free text); 61% was omitted, inferred, or in conflict with the paper record.
Conclusion:
The results of this study show that recording patient data using structured data entry does not necessarily lead to uniformly structured data.
Related Concept Videos
Methods of Documentation I: Source-Oriented Records
In an SOR, each discipline involved in patient care maintains a separate medical record section. This record-keeping method enables easy tracking of patient progress and ensures healthcare staff have access to up-to-date information.
Key Attributes include the following:
Flow Sheet
Here's a closer look at the examples of flowsheets commonly used by nurses:
Graphic Sheet Documentation:
Formats for Nursing Documentation
Nursing Assessment Form:
• A nursing assessment form is a foundational document that captures detailed patient data from physical assessments and nursing histories.
• It includes patient demographics, medical history, current medications, vital...
Data Reporting and Recording
Documentation in Long-Term and Home Healthcare Setting
Long-Term Care Facilities
Data Collection III
The principles to begin the physical assessment include conducting a comprehensive or problem-related history in a quiet, well-lit room, emphasizing privacy and comfort for the patient.
