Schema: Uncategorised Data
What is Uncategorised Data?
There is data that a clinician/user will enter without identifying what type of information they are recording. This information is usually entered as a combination of clinical code(s), values, qualifiers and text.
For example:
the clinician records the patient’s resting pulse by recording the resting pulse clinical code followed by a value of the patient’s pulse.
the clinician records that a patient has a sore throat by recording the sore throat clinical code
Consideration was given to attempting to categorise data using the recorded clinical codes. It was decided not to progress this based on a clinical review of its risks and benefits.
Uncategorised Data Definition
Uncategorised data will include the following
data items in the patient record that do not fit into one of the existing or planned clinical areas:
Allergy
Appointment
Consultation
Demographics
Diary Entry
Flag/Alert
Immunisation
Investigation
Medication and Medical Device
Problem
Referral
Test Request
inbound referrals (GP Connect referral resource is defined as outbound referrals only)
Where text is entered freely into a consultation without being associated with a clinical code it will not be extracted as an item of uncategorised data. This free text will ONLY be extracted as part of the consultation and will be extracted in an Observation with the SNOMED code 37331000000100 Comment note.