Structured data entry of clinical information for documentation and data collection
Cheung, N.T.; Fung, V.; Chow, Y.Y.; Tung, Y.
Studies in Health Technology and Informatics 84(Pt 1): 609-613
2001
ISSN/ISBN: 0926-9630 PMID: 11604809 Document Number: 537370
Routine databases containing large amounts of clinical data represent a tremendous opportunity for the evaluation of health care practices and outcomes. However, data collected for administrative purposes has limitations in content, accuracy and completeness. Routine entry of clinical information directly into clinical information systems by care providers is one strategy to address this problem. We developed a structured data entry method, the Clinical Data Framework (CDF), which has been used to support the capture of clinical information by clinicians in the normal process of care delivery. A study of the CDF over a two month period showed that it improved the accuracy of completeness of data collection over a coding method which was based on selection of ICD-9-CM codes.