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)

Shah et al.

Shah et al. BMC Medical Informatics and Decision Making 2012 12:88   doi:10.1186/1472-6947-12-88

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