Rijk MH, Platteel TN, Mulder MMM, Geersing GJ, Rutten FH, van Smeden M, Venekamp RP, Leeuwenberg TM. Incomplete and possibly selective recording of signs, symptoms, and measurements in free text fields of primary care electronic health records of adults with lower respiratory tract infections.
J Clin Epidemiol 2024;
166:111240. [PMID:
38072176 DOI:
10.1016/j.jclinepi.2023.111240]
[Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2023] [Revised: 11/17/2023] [Accepted: 12/05/2023] [Indexed: 01/05/2024]
Abstract
OBJECTIVES
To assess the completeness of recording of relevant signs, symptoms, and measurements in Dutch free text fields of primary care electronic health records (EHR) of adults with lower respiratory tract infections (LRTI).
STUDY DESIGN AND SETTING
Retrospective cohort study embedded in a prediction modeling project using routine health care data of the Julius General Practitioners' Network of adult patients with LRTI. Free text fields of 1,000 primary care consultations of LRTI episodes between 2016 and 2019 were manually annotated to retrieve data on the recording of sixteen relevant signs, symptoms, and measurements.
RESULTS
For 12/16 (75%) of the relevant signs, symptoms, and measurements, more than 50% of the values was not recorded. The patterns of recorded values indicated selective recording of positive or abnormal values. Recording rates varied across consultation type (physical consultation vs. home visit), diagnosis (acute bronchitis vs. pneumonia), antibiotic prescription issued (yes vs. no), and between practices.
CONCLUSION
In EHR of primary care LRTI patients, recording of signs, symptoms, and measurements in free text fields is incomplete and possibly selective. When using free text data in EHR-based research, careful consideration of its recording patterns and appropriate missing data handling techniques is therefore required.
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