Table 1.

Examples of structured and unstructured data within general practice medical records

Data item	Examples
	Structured*	Unstructured
Time	dd/mm/yyyy 14 September 2017 Prescription start date: dd/mm/yy	‘Earlier today Mr X experienced chest pain’ ‘Operation scheduled on Tuesday’.
Symptoms	N242300 Neuropathic pain 1B1B.00 Cannot sleep—insomnia	‘…c/o shooting pain in upper right leg during the night, disturbing her sleep’
Diagnosis	C109912 Type 2 diabetes without complication	‘The patient has diabetes without complications’
Prescription	01040200 (BNF code for codeine phosphate 60 mg tablets)	‘Px codeine 60 mg PO qid×7 days’
Referral	8H4D.00 Referral to psychogeriatrician	Rev 4 w ?refer pyscho ger
Test	43F1.00 Rheumatoid factor positive	Rheumatoid 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.