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Textual content, health problems and diagnostic codes in electronic patient records in general practice
Allmänmedicin Karolinska Institutet.
Linköping University, The Institute of Technology. Linköping University, Department of Biomedical Engineering, Medical Informatics.
Allmänmedicin Karolinska Institutet.
2003 (English)In: Scandinavian Journal of Primary Health Care, ISSN 0281-3432, E-ISSN 1502-7724, Vol. 21, no 1, 33-36 p.Article in journal (Refereed) Published
Abstract [en]

Objective - To investigate textual content, health problems and diagnostic codes in everyday electronic patient records. Design - Retrospective and observational database study. Setting - Primary health care in Stockholm. Subjects - Twenty randomly selected general practitioners with 20 records each. Main outcome measures - The frequency of use of problem-oriented medical records. The number of words, problems and diagnostic codes. The completeness and correctness of the diagnostic codes. Results - About 14.5% of 400 studied records were problem-oriented. The mean number of words per record was 99.4, and the mean number of problems managed per record was 1.2. On average, there were 1.1 diagnostic codes per record and this differed widely among GPs and also among the electronic patient record systems. The mean number of codes per problem was 0.9, and the proportion of correct codes was 97.4%. Conclusions - The electronic patient records in general practice in Stockholm have an extensive textual content. A vast majority of the problems are coded and the completeness and correctness of diagnostic codes are high. It seems that problem-oriented electronic patient record systems enforce coding activities. It is feasible to establish a database of diagnostic data for research and health care planning based on electronic patient records.

Place, publisher, year, edition, pages
2003. Vol. 21, no 1, 33-36 p.
National Category
Medical and Health Sciences
Identifiers
URN: urn:nbn:se:liu:diva-24494DOI: 10.1080/02813430310000537Local ID: 6618OAI: oai:DiVA.org:liu-24494DiVA: diva2:244815
Available from: 2009-10-07 Created: 2009-10-07 Last updated: 2017-12-13

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Åhlfeldt, Hans

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CiteExportLink to record
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Citation style
  • apa
  • harvard1
  • ieee
  • modern-language-association-8th-edition
  • vancouver
  • oxford
  • Other style
More styles
Language
  • de-DE
  • en-GB
  • en-US
  • fi-FI
  • nn-NO
  • nn-NB
  • sv-SE
  • Other locale
More languages
Output format
  • html
  • text
  • asciidoc
  • rtf