Coding of procedures documented by general practitioners in Swedish primary care-an explorative study using two procedure coding systems

Procedures in 200 record entries were identified, coded, assessed in relation to two procedure coding systems and analysed.417 procedures found in the 200 electronic patient record entries were coded with 36 different Classification of Health Interventions categories and 148 different SNOMED CT concepts. 22.8% of the procedures could not be coded with any Classification of Health Interventions category and 4.3% could not be coded with any SNOMED CT concept. 206 procedure-concept/category pairs were assessed as a complete match in SNOMED CT compared to 10 in the Classification of Health Interventions.Procedures documented by general practitioners were present in nearly all electronic patient record entries. Almost all procedures could be coded using SNOMED CT.Classification of Health Interventions covered the procedures to a lesser extent and with a much lower degree of concordance. SNOMED CT is a more flexible terminology system that can be used for different purposes for procedure coding in primary care.Primary care in Sweden, with general practice as the core medical specialty, provides ambulatory and home health care outside hospitals. It is regarded as a fundamental constituent of the health care system in Sweden [1] and accounts for 17% of the net costs of health care in the country [2].Different professionals such as general practitioners (GPs), district nurses, physiotherapists and occupational therapists work in primary care and are required by Swedish law to carry out health care documentation, which is normally done in electronic patient records (EPRs). Health care documentation in Swedish primary care is often considered poorly organized and difficult to use for secondary purposes such as research and follow-up, or for sharing between different EPRs [3]. Narrative, free-text documentation in EPRs is still common.Structuring and coding of information in EPRs in primary care has been suggested to hold great potential. It may provide a source for research an