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J Am Med Inform Assoc 7:42-54 doi:10.1136/jamia.2000.0070042
  • Original Investigation

Exploring the Degree of Concordance of Coded and Textual Data in Answering Clinical Queries from a Clinical Data Repository

Table 1

Questions Asked and Fields Searched to Determine Answers

Question* Criteria for Inclusion in Search Field Searched Type of Field Person Entering Data Time Entered (in Relation to Event) Search Criteria
Postoperative pulmonary embolism Presence of dictated discharge summary Postoperative complication Coded Surgical risk coordinator When event disclosed “Pulmonary embolism”
ICD-9-coded discharge diagnosis Coded Medical records personnel After discharge from hospital Codes for pulmonary embolism (415.1, 415.11, 415.19)
Operation on this or previous admission prior to embolism Dictated discharge summary Free text Clinician in charge of patient at time of discharge At or close to time of discharge Mention of pulmonary embolism, PE, or VQ scan
Wound infection Presence of dictated discharge summary Postoperative infection Coded Surgical risk coordinator after determination by nurse epidemiologist When event discovered “Yes”
Postoperative complication Coded Surgical risk coordinator after determination by nurse epidemiologist When event discovered “Wound infection”
ICD-9-coded discharge diagnosis Coded Medical records personnel After discharge from hospital Codes for postoperative infection (998.5, 998.51, 998.59)
Dictated discharge summary Free text Clinician in charge of patient at time of discharge At or close to time of discharge Mention of “wound infection”
Hernia Presence of dictated operative note Postoperative diagnosis Coded Surgical team At completion of operation “*Hernia*rdquo; or “?ih*”
Primary procedure Coded Surgical team At completion of operation “*Hernia*” or “?ih*”
Dictated operative note Free text Surgeon performing procedure Following procedure Mention of hernia
ICD-9-coded discharge diagnosis Coded Medical records personnel After discharge from hospital Codes for adbominal or groin hernia (550 to 553)
Dictated discharge summary Free text Clinician in charge of patient at time of discharge At or close to time of discharge Mention of hernia

  • ↵* Questions are given in their entirety in the text.

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