Table 3.
Distribution of ‘dementia’ text according to data entry field in the EPR.
| EPR section | Sub-section | Free-text data collection field | Frequency of ‘dementia’ recorded (n = 29,984) | 65+ records with ‘dementia’ present in EPR with ‘dementia’ in this field (N = 20,014) |
|---|---|---|---|---|
| Incident | Patient | Social history notes | 413 | 2.1% |
| Presenting condition | Presenting condition/chief complaint (free text following main ‘choice’ field) | 5098 | 25.5% | |
| AMPLE* | Past medical history | Other known medical history | 9128 | 45.6% |
| Other known neurological medical history | 4207 | 21.0% | ||
| Examination | Mental health | Mental health notes | 3794 | 19.0% |
| Mental health diagnosis — further information | 61 | 0.3% | ||
| Mental health diagnosis — notes | 22 | 0.1% | ||
| General | Brief description of injury or illness | 3123 | 15.6% | |
| Signs and symptoms | 1160 | 5.8% | ||
| What are the clinician’s concerns? (relating to falls risk assessment concerns) | 325 | 1.6% | ||
| Previous medical history including falls (any patterns?) (relating to falls risk assessment past medical history) | 1091 | 5.5% | ||
| Patients confirmed diagnosed conditions (relating to falls risk assessment confirmed/diagnosed) | 1088 | 5.4% | ||
| Final disposition | Impression and plan | Further information regarding diagnosis (‘impression differential diagnosis’) | 101 | 0.5% |
| Impression | 251 | 1.3% | ||
| Impression working diagnosis | 72 | 0.4% | ||
| Non-conveyance | Diagnosis notes (relating to ‘SeeTreatFreetext’) | 50 | 0.2% |
*AMPLE = Allergies, Medications, Past medical history, Last oral intake, Events leading to.