Representation of clinical problem assessment phrases in U.S. family practice using Read version 3.1 terms: a preliminary study.
The Read Codes from the United Kingdom are a comprehensive clinical vocabulary, and one of the most likely candidates for adoption as a standard for use in Computer-Based Patient Record (CPR) systems. The new version 3.1 codes represent a major enhancement to the content and structure of the coding system, including incorporation of a new hierarchy and an explicit model for the use of qualifier terms. This is a preliminary study investigating the suitability of these codes for representing clinical problem assessment phrases in U.S. family practice. Problem assessment phrases from outpatient progress notes were encoded into the equivalent Read terms. The problem assessment phrases were evaluated for complexity and clarity. The coded representations of the phrases were evaluated for clinical acceptability. A list of coding difficulties was compiled. The most common difficulties were (1) qualifier terms present but not allowable for that Read concept (24%), and (2) qualifier terms not present (20%). British spelling and abbreviation variants were noted, but were relatively insignificant. The Read codes appear to be suitable for use in U.S. primary care practice with fairly minor modifications, but further development is required to expand the content and structure of the model for qualifier terms.
Hausam
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RR
Medical Informatics Group, University of Missouri-Columbia, USA.
Hahn
A W
AW
D005194:Family Practice; D006801:Humans; D016247:Information Storage and Retrieval / Q000145:classification / Q000592:standards; D016347:Medical Records Systems, Computerized / Q000145:classification* / Q000592:standards; D008501:Medical Records, Problem-Oriented; D014481:United States; D018875:Vocabulary, Controlled