Table 1 Definitions of terms used throughout this paper*

International Classification of Primary Care, Version 2 (ICPC-2):

A classification developed by the World Organisation of Family Doctors (WONCA). ICPC chapters are based on body systems, following the principle that localisation has precedence over aetiology.

ICPC-2 PLUS:

An interface terminology classified to ICPC-2. ICPC-2 PLUS includes the terms used by general medical practitioners to describe three important elements of the healthcare encounter: patient reasons for encounter (RFE); problems or diagnoses managed; and process of care (such as procedures, counselling and referrals).

Chapters (ICPC-2):

The main divisions within ICPC-2. There are 17 chapters primarily representing the body systems.

Code:

In ICPC-2 this is a 3-digit alphanumeric code. In ICPC-2 PLUS this is a 6-digit alpha numeric code made up of the ICPC-2 code followed by a three digit term identifier.

Diagnosis/problem:

A statement of the healthcare provider’s understanding of a health problem presented by a patient, family or community. Healthcare providers are instructed to record at the most specific level possible from the information available at the time. It may be limited to the level of symptoms.

Encounter:

Any professional interchange between a patient and a healthcare provider.

Keywords:

These are used as the links to access the term in ICPC-2 PLUS. Keywords may be terms, synonyms, acronyms, etcetera, and are linked to ICPC-2 PLUS terms to facilitate data entry. Multiple keywords can be linked to a single term.

Groups:

A collection of ICPC-2 diagnosis/problem rubrics created for reporting purposes.

Process of care:

An action the health provider carries out related to the encounter, including treatment/care provided, advice given, referral to another provider, and orders for pathology or imaging.

Reason(s) for encounter (RFEs):

The subjective reason(s) given by the patient for seeing or contacting the healthcare provider. These can be expressed in terms of a symptom, diagnosis or the need for a service.

Rubric:

The title of an individual code in ICPC-2.

Term:

In the PLUS terminology, this is a structured expression of the free text description recorded by the clinician. There are currently approximately 8,000 terms within the ICPC-2 PLUS system. Terms may represent a disease (e.g. hypertension), a symptom (e.g. cough) or a procedure (e.g. dressing).