Hogan W R, Wagner M M
Center for Biomedical Informatics University of Pittsburgh, USA.
Proc AMIA Annu Fall Symp. 1996:517-21.
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.
研究人员主张在电子病历（EMR）中用自由文本字段补充编码字段，以便临床医生在数据录入过程中具有灵活性。他们列举了能更完整地捕获数据以及提高临床医生对电子病历的接受度和使用率等优点。然而，自由文本可能存在改变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用药数据时所做的自由文本录入。我们发现这些录入改变了编码数据的含义，并降低了我们电子病历中医疗决策支持系统（MDSS）的数据准确性。我们得出结论，临床医生所做的补充自由文本录入经常会改变编码数据的含义。
