Table 1

Read codes from general practice patient records and examples of accompanying free text

CodeAccompanying text
N06z.11 ArthritisGenerally worse—quite immobile at times—knees and wrists swollen
N245.14 Hand painPain in small joints in both hands—some hurt more than others. Wrists also in problem. O/E—tender over MCP and PIP joints of the index finger in both hands. Wrist movement painful. No joint swelling
6A…00 Patient reviewedIncreased joint pains, concerned if SE of hydroxychloroquine. Pain in shoulders and hands on mobilisation—more likely to be Rh A, awaiting appointment at rheumatology
8C1B.00 Nursing care blood sample takenFBC, ESR, UE, SLFT, fasting glucose, TFT, CHOL, CRP, PSA, urate
1992.00 VomitingSince waking this morning. No haemoptysis. O/E—looks pale and unwell. Abdomen soft, bowel normal. Had a motion this morning/normal. Stop prednisolone and indometacin. Twice omeprazole and take gaviscon (QDS). Do Hb/ESR/CRP to check progress of arthritis. Symptoms of arthritis completely disappeared. No history of indigestion
  • CHOL, cholesterol; CRP, C reactive protein; ESR, erythrocyte sedimentation rate; FBC, full blood count; Hb, haemoglobin; MCP, metacarpophalangeal; O/E, on examination; PIP, proximal interphalangeal; PSA, prostate specific antigen; Rh A, rheumatoid arthritis; SE, side effect; SLFT, liver function test; TFT, thyroid function test; UE, urea and electrolytes.