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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