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

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.

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.

We will search the following databases for evidence of published and unpublished material: CINAHL; EMBASE; Google Scholar; IndMED; LILACS; MEDLINE; NIHR; Paklit and PsycINFO.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.

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.

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.