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Table 2 Examples of categorisation of data extracted from electronic medical records

From: Management of patients with persistent medically unexplained symptoms: a descriptive study

Patient

Length of record

Information extracted from medical records

Categorised as

113

≤10 words

Had a talk. Gave explanation.

Diagnostic:

None

Therapeutic:

- Education and explanation

- Discussing progress

- Other: “talk”

171

≤10 words

Physical examination, referral to neurologist

Diagnostic:

- Physical examination

Therapeutic:

- Referral to secondary care (unclear for diagnostics or treatment): neurologist

115

11–30 words

Explained that I don’t know whether a scan is indicated, but that due to the long duration of complaints we can ask for the orthopedist’s opinion: referral

Diagnostic:

- Diagnostic referral

Therapeutic:

- Education and explanation

123

11–30 words

Stop tramal, start fentanyl patch, and follow up appointment after 2 weeks, is allergic to diclofenac, developed a rash, fentanyl patch 12 mcg/hr. 5 pieces

Diagnostic:

None

Therapeutic:

- Medication adjustment: discontinuation

- Prescribed medication: opioids

- Follow-up appointment

158

≥31 words

Carried out physical examination. Exploration. Does not feel reassured despite good lab results and echo abdomen. Will go to exercise therapist and an optometrist for visual test. Will return in a month for an evaluation. If there is insufficient improvement, referral to a psychiatrist. In my opinion no indication of physical cause. Patient will also fill in a diary with symptoms (because complaints are very inconsistent). Explanation when to return sooner.

Diagnostic:

- Exploration of symptoms

- Physical examination

- Discussing test results

Therapeutic:

- Education and explanation

- Symptom diary

- Discussing progress

- Follow-up appointment

165

≥31 words

Gave explanation: No somatic problem, no reason to be extra vigilant with normal heartbeat. Talked about the option to talk to the behaviour specialist, is going to do this. Will go to physiotherapist to learn not to focus on his normal heartbeat. Wants to go there as well because wants to hear from a professional whether everything is OK during a workout, prefers not to start a long treatment program (psychosomatic physiotherapy?)

Diagnostic:

None

Therapeutic:

- Education and explanation

- Referral within primary care: other

GP consulting another health professional: other