Actually, the preferred method is to record the "free text utterance"
of the clinician and attach a coded term to that.
Recording only a coded term loses richness and therefore usefulness
for human decision makers.
Text can be coded after the fact with well designed tools.
Loss of specific information is much harder to recreate.
Ian.
At 5:20 pm +1000 20/7/06, Greg Twyford wrote:
Michael Tooth wrote:
Peter Machell wrote:
On 20/07/2006, at 12:13 PM, Greg Twyford wrote:
GPs are already coding data in programs like MD. It's diagnosis/ past
history dialogues have forced them to consciously avoid using the
available coded entries if they don't want to use them, and enter
uncoded stuff instead.
Most of the MD users I see enter free text for all notes, and are
offended when I suggest they first use the 'Reason' button. Isn't
it time that coded diagnosis be made the default entry method,
with free text a last resort?
You might remember that MD originally only had the coded option, but
that the ability to put uncoded in was really the result of there not
being enough DOCLE codes.
Michael,
Originally it MD it was much easier for GPs to end up with their own
search entries like 'dia' in their notes, which were meaningless in
terms of coding, when trying to bring up the coded diagnosis
'diabetes', for example.
The dialogue was changed to reduce the likelihood of this by placing
the free text box down the bottom and by changing the action of the
search entry box at the top. It's new action ensured that one of the
coded diagnoses was entered from the list when a search entry like
'dia' was used in the default search entry box at the top.
This effectively forced selection of a coded diagnosis/reason/past
history item unless the bottom 'free text' box was consciously
clicked on.
They also included the diagnosis coding tool in maintenance to allow
uncoded or meaningless entries in the database to be corrected or
linked with coded ones.
Greg
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