Table 1 Categorization of data elements in electronic medical records (EMR) by type: structured, unstructured, and hybrid data formats
From: A roadmap to precision medicine through post-genomic electronic medical records
Data elements | Description | Common formats/examples |
|---|---|---|
Structured | ||
Billing Information | Details related to medical charges | HCPCS codes, DRG codes |
Diagnostic Codes | Codes indicating clinical diagnosis | ICD-10-CM codes |
Immunization Records | Vaccination history | CVX codes |
Laboratory Results | Outcomes of lab tests | LOINC codes |
Patient Demographics | Records of patient’s general characteristics | Names, DOB, Sex, Race |
Patient Identifiers | Unique identifiers for each patient | Facility ID, Medical Record ID |
Surgical Codes | Codes indicating surgical procedures | CPT codes, ICD-10-PCS codes |
Visit Identifiers | Unique identifiers for each hospital visit | Encounter ID |
Unstructured | ||
Clinical Notes | Notes from healthcare professionals | Physicians’ notes, nurses’ notes |
Correspondence | Communication among healthcare staff and patients | Letters, emails |
Discharge Summaries | Summaries of hospital stay and instructions | Free-text summaries |
Pathology Reports | Descriptions of biopsy, surgical specimen findings | Free-text reports |
Pulmonary Notes | Description of spirometry tests, findings, and images | Mixed of free-text summaries and images |
Cardiology Notes | Description of cardiac tests, findings, and images | Mixed of free-text summaries and images |
Endoscopy Reports | Description of endoscopy findings, and images | Mixed of free-text summaries and images |
Progress Notes | Regular updates on patient’s health status | Free-text descriptions |
Scanned Documents | Digitized versions of paper documents | Scanned images |
Both structured and unstructured | ||
Allergies | Recorded adverse reactions | Free-text description or SNOMED CT |
Family History | Health status of family members | Free-text narrative or SNOMED CT |
Medication Orders | Details of prescribed drugs | Free-text description or RxNorm codes |
Patient History | Past and present health status | Free-text narrative or SNOMED CT |
Radiology Reports | Interpretations of imaging studies | Free-text descriptions or DICOM files |
