Standardised clinical data capture: Optimisation of Allied Health clinical activity recording in an ieMR for admitted patient care

Ms Kristy Perkins1, Jill Mahoney2, Alicia Chaplain3, Catherine Stephens3

1West Moreton Health, Queensland Health, Ipswich, Australia, 2Gold Coast Health, , Australia, 3The Allied Health Professions Office of Queensland, , Australia

Background: The Queensland Digital Reporting Working Group was formed to guide the development of an ieMR generated allied health reporting suite aligned to the Allied Health National Best Practice Data Set (AHNBPDS). The inclusion of clinical, activity and administrative data within the AHNBPDS, was seen as an opportunity to determine patients and conditions which allied health professionals treat; identify allied health interventions and demonstrate the contribution of allied health services to health outcomes.

Methods: The AHNBPDS were mapped within the Queensland ieMR to identify appropriate fields and coded recording options. ieMR Clinical data fields were analysed against the data elements and SNOMED CT- AU Allied Health Clinical reference set terminology. Additional work prioritised clinical elements and investigated recording solutions within ieMR.

Results: The majority of AHNBPDS activity and administrative data elements are available within the Queensland ieMR. AHNBPDS clinical data elements are not captured in a codified way, however the coded ‘Reason for Consult’ field could map to ‘Indicator for Intervention’ with future codeset modification. An Intervention SNOMED CT- AU Allied Health Clinical reference set subset was identified and piloted at West Moreton Health via manual text entry in a field that is able to be collated and reported on.

Discussion: The ability to collect standardised allied health activity and clinical data is a priority for allied health leaders to demonstrate the value of allied health services and inform service requirements. Future work will focus on codifying ‘Intervention’ terms and potentially modifying the ‘Reason for Consult’ codeset in the ieMR.


Alicia Chaplain is a registered Occupational Therapist with a wealth of experience in clinical work both within Australia and the UK. She developed the first Allied Health Clinical Reference set in SNOMED CT-AU to advance clinical informatics for use in electronic medical records. Alicia is committed to supporting the development of allied health clinical informatics in Queensland and Nationally.

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