Free-text fields change the meaning of coded data.

机译：自由文本字段更改了编码数据的含义。

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摘要

Researchers have advocated the supplementation of coded fields with free-text fields in electronic medical records (EMRs) to provide clinicians with flexibility during data entry. They cite advantages of more complete data capture and improved clinician acceptance and use of the EMR. However, free text may have the disadvantage of changing the meaning of coded data, which causes lower data accuracy for applications that cannot read free text. We studied the free-text entries that clinicians made during the recording of medication data. We found that these entries changed the meaning of coded data and lowered data accuracy for the medical decision-support system (MDSS) in our EMR. We conclude that supplemental free-text entries made by clinicians frequently alter the meaning of coded data.

机译：研究人员主张用电子病历（EMR）中的自由文本字段补充编码字段，以在数据输入过程中为临床医生提供灵活性。他们列举了更完整的数据采集以及改进的临床医生对EMR的接受和使用的优势。但是，自由文本可能具有更改编码数据含义的缺点，这会导致无法读取自由文本的应用程序的数据准确性降低。我们研究了临床医生在记录药物数据时输入的自由文本条目。我们发现这些条目改变了EMR中医疗决策支持系统（MDSS）的编码数据的含义，并降低了数据准确性。我们得出的结论是，临床医生做出的补充性自由文本条目经常会更改编码数据的含义。

著录项

期刊名称 AMIA Annual Symposium Proceedings
作者
W. R. Hogan; M. M. Wagner;
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年(卷),期 1996(517–521),-1
年度 1996
页码 517–521
总页数 5
原文格式 PDF
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Free-text fields change the meaning of coded data.

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