Electronic health records use a variety of data entry methods that are often customized to clinician needs. Data entry interfaces must be appropriately designed to maximize benefits and minimize unintended consequences. There was relatively little evidence in the literature to guide the selection of specific data entry methods according to the type of data documented. This literature review summarizes existing data entry design recommendations to guide data entry interface design. Structured data entry uses predefined charting elements to limit acceptable data entry to standard coded data and improve completeness and data reuse at the expense of correctness. Unstructured data entry methods use natural language and improve correctness, at the expense of completeness and data reusability. Semistructured data entry uses a combination of these data entry methods to complement the strengths and minimize the weaknesses of each method. Documentation quality is influenced by the method of data entry. It is important to choose data entry methods based on the type of data to be documented. This literature review summarizes data entry design guidelines to inform clinical practice and future research.
This work has been funded by the American Association of Nurse Anesthetists Foundation through a dissertation research grant.
The authors have disclosed that they have no significant relationships with, or financial interest in, any commercial companies pertaining to this article.
Corresponding author: Bryan A. Wilbanks, DNP, CRNA, 1112 Ford Chapel Rd, Harvest, AL 35749 (Bryan004@UAB.edu).
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