Textual content, health problems and diagnostic codes in electronic patient records in general practice.
OBJECTIVE
To investigate textual content, health problems and diagnostic codes in everyday electronic patient records.


METHODS
Retrospective and observational database study.


METHODS
Primary health care in Stockholm.


METHODS
Twenty randomly selected general practitioners with 20 records each.


METHODS
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.
Nilsson
Gunnar
G
Department of Clinical Science, Family Medicine Stockholm, Karolinska Institutet, Stockholm, Sweden. gunnar.nilsson@nlpo.sll.se
Ahlfeldt
Hans
H
Strender
Lars-Erik
LE
D004194:Disease / Q000145:classification; D005194:Family Practice / Q000458:organization & administration*; D006302:Health Services Research; D006801:Humans; D038801:International Classification of Diseases; D016347:Medical Records Systems, Computerized; D008501:Medical Records, Problem-Oriented; D008875:Middle Aged; D012189:Retrospective Studies; D013548:Sweden