Table 1 Field composition, data type and recording method of outpatient medical records in the ESR system
From: Evaluation of the clinical application effect of eSource record tools for clinical research
Field name | Data type | Main recording method |
|---|---|---|
Demographics | Structured | Optical character recognition |
Visit time | Structured | Voice input |
History of present illness | Free text | Voice recognition/NLP parsing transcribed text to generate records |
Past history | Free text | Voice recognition/NLP parsing transcribed text to generate records |
Personal history | Free text | Voice recognition/NLP parsing transcribed text to generate records |
Menstrual history | Free text | Voice recognition/NLP parsing transcribed text to generate records |
Marriage history | Free text | Voice recognition/NLP parsing transcribed text to generate records |
Physical examination | Free text | Voice input |
Specialty situation | Free text | Voice input |
Auxiliary examination | Free text | Voice input/optical character recognition |
Initial diagnosis | Structured | Voice input |
Treatment plan | Free text | Voice input |