Table 2 Examples of unsupported text (demarked by square brackets).
type | annotated | example |
|---|---|---|
dates (none mentioned) | Y | PSA 0.6 ng/mL[, 05/25/2021] |
exam | Y | [Consitutional: Well-developed, well-nourished, in no apparent distress] |
Y | Neck: [Supple without thyromegaly or lymphadenopathy.] No carotid bruits appreciable. | |
medication context | Y | 1 tablet [by oral route] daily |
medical reasoning | Y | recommended that we obtain an MRI of the right shoulder [to evaluate for a possible rotator cuff tear]. |
Y | referred her to formal physical therpay [to strengthen her right shoulder] | |
patient acquiescence | Y | [All questions were answered.] |
Y | [The patient understands and agrees with the recommended medical treatment plan] | |
review of system | Y | Ears, Nose, Mouth and Throat: [Denies ear pain, hearing loss, or discharge.] Endorses nasal congestion from allergies. |
vitals | Y | [Blood Pressure:124/82 mmHg] |
dates (year kept if only month mentioned) | N | 03/[2022] |
higher granularity problem/test/treatment | N | diabetes [type II] |
N | [3 views] of the shoulder | |
N | MRI [of the head] | |
measurements | N | 25 [mg/dl] |
patient name/age | N | [John Smith] is a 53-year-old male |
other names | N | he was seen by Jane [Smith, PA-C] |
