Table 1 Examples of free text associated with read terms analysed by the freetext matching algorithm
Analysis mode | Read term | Free text | Structured output |
|---|---|---|---|
Standard | 55...11 Angiography - CVS | coronary severe triple vessel disease + impaired function | Read G340.11 Triple vessel disease of the heart |
Standard | G20..00 Essential hypertension | 176/100 but only taking doxaz 4mg od not bd as pw intended - increase to 4mg bd, pn recheck 4w please. otherwise isq but recent diagnosis ca prostate - seeing urol 1w - reassured re treatablility of this nowadays | Systolic BP: 176, Diastolic BP: 100, Follow up: 4 weeks, Read B46..00 Malignant neoplasm of prostate |
Standard | 32...00 Electrocardiography | sinus bradycardia (58 bpm) nonspecific intraventricular conduction delay | Read R059.00 [D]Sinus bradycardia, Pulse: 58 |
Standard | 55...12 Angiogram | ct did not show renal artery stenosis. | Negative: Read P769000 Renal artery stenosis |
Standard, append | G581.00 Left ventricular failure | acute give lasix and o2 and admitted | Read G581000 Acute left ventricular failure, Read 8H3Z.00 Other hospital admission NOS |
Standard, append | 14A4.00 H/O: myocardial infarct >60 | had an mi in 1996 | Past medical history: Read G30..00 Acute myocardial infarction, date: year 1996 |
Death | 22J..12 Death | found dead by family this afternoon, called ambulance, cd 1415hrs, sudden death, rpt to coroner | Read 213100 [D]Found Dead, Time: 14:15, OXMIS T4002 SUDDEN DEATH |
Labtest | 42J..00 Neutrophil count | original result: ’neutrophil count’ = 4.17 x109 / l (1. 5 - 7. 5) | Lab result: 4.17 |
Sicknote | 9D2..00 MED5 - doctor’s special stat. | ### 09/01/2007 1 month heart problems, ### | Sickness certificate date: 9-Jan-2007, duration: 1 month |
Examples of errors in interpretation of free text | |||
Standard | 5853.11 Echocardiogram | significant mitral regurg | (no output; ‘regurg’ not recognised as an abbreviation for ‘regurgitation’) |
Standard | 33B9500 Exercise tolerance test abnormal | pt exercised according to the bruce protocol for 4 mins 39secs. he developed chest discomfort during the test with very significant, >3mm, st depression in leads v4, 5 and 6 and leads 2, 3 avf. ### | Read R065600 [D]Chest discomfort, Read E2B..00 Depressive disorder NEC (incorrect interpretation of ECG finding of ST segment depression) |