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Benefits and risks of structuring and/or coding the presenting patient history in the electronic health record: systematic review.

Fernando, B; Kalra, D; Morrison, Z; Byrne, E; Sheikh, A; (2012) Benefits and risks of structuring and/or coding the presenting patient history in the electronic health record: systematic review. BMJ Qual Saf , 21 (4) 337 - 346. 10.1136/bmjqs-2011-000450.

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Abstract

Patient histories in electronic health records currently exist mainly in free text format thereby limiting the possibility that decision support technology may contribute to the accuracy and timeliness of clinical diagnoses. Structuring and/or coding make patient histories potentially computable.

Type: Article
Title: Benefits and risks of structuring and/or coding the presenting patient history in the electronic health record: systematic review.
Location: England
DOI: 10.1136/bmjqs-2011-000450
Language: English
Keywords: Clinical Coding, Electronic Health Records, Humans, Information Storage and Retrieval, Medical History Taking, Risk Assessment
UCL classification: UCL > School of Life and Medical Sciences > Faculty of Population Health Sciences > Institute of Epidemiology and Health Care > CHIME
URI: http://discovery.ucl.ac.uk/id/eprint/1340924
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