Table 1

Examples of structured and unstructured data within general practice medical records

Data itemExamples
Structured* Unstructured
14 September 2017
Prescription start date: dd/mm/yy
‘Earlier today Mr X experienced chest pain’
‘Operation scheduled on Tuesday’.
SymptomsN242300 Neuropathic pain
1B1B.00 Cannot sleep—insomnia
‘…c/o shooting pain in upper right leg during the night, disturbing her sleep’
DiagnosisC109912 Type 2 diabetes without complication‘The patient has diabetes without complications’
Prescription01040200 (BNF code for codeine phosphate 60 mg tablets)‘Px codeine 60 mg PO qid×7 days’
Referral8H4D.00 Referral to psychogeriatricianRev 4 w ?refer pyscho ger
Test43F1.00 Rheumatoid factor positiveRheumatoid factor was 42 IU/mL which is a positive result
  • *These codes represent Read codes, a UK-based, alphanumeric clinical coding system for general practice, and British National Formulary (BNF) codes, which represent the full list of medications available in the UK.