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For the CCC cohort, persons were considered to have a history of IDU if there was any record of IDU as self-reported probable route of HIV infection, or any corresponding ICD-9 diagnoses or free text entered into the EMR by providers.
We used a qualitative research design to conduct a thematic analysis of free text entered into an electronic prescribing system.
CiPCA contains the first 220 characters of free text entered at the consultation; there are no standard requirements for free text use in CiPCA practices.
In the Dutch database we could utilise all free text entered in the medical record, enabling us to look for more detailed information in clinical letters, resulting in higher proportion of risk factors, such as presence of oesophagitis and a hiatal hernia at time of BO diagnosis as compared with the UK database, in which we relied on diagnosis codes.
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Data from protocols, both dichotomised data and free text, were entered into an Excel spreadsheet (MS Excel, Microsoft Corporation, Redmond, WA 98052-6399, USandand checked for consistency and correctness.
For free text information entered by GPs in the course of their consultation, there is likely to be a wide range of ways to express similar concepts and it is known that many entries have spelling errors or use abbreviations.
Although laboratory workers could enter test results by using preprogrammed codes or free text (non-coded, non-standardized text entered by a laboratory personnel), the electronic laboratory-based reporting system monitored only coded organism names in each HL7 culture message.
Free text comments were entered to Microsoft Word and analysed thematically.
Free text responses were entered onto Microsoft Word and subject to thematic analysis using the framework approach [ 14] which supported examination of responses relevant to research objectives and matters arising in respondents' comments.
Some users were critical of the documentation generated by use of the templates, so they entered free text into the template instead of or in addition to filling in the fields.
Of note, the EHRs at these facilities allow both coded and free text diagnosis to be entered into the problem list, providing the practitioners with great freedom in how they approach the problem list.
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Justyna Jupowicz-Kozak
CEO of Professional Science Editing for Scientists @ prosciediting.com