SUPPLEMENTARY MATERIAL

CRITICAL CARE DISCHARGE SUMMARIES ANNOTATION GUIDELINES1

Authored and Reviewed by: St. John’s Research Institute, St. John’s Medical College Hospital & RelAgent Technologies (P) Ltd

Table of Contents

Overview.................................................................................................................................. 26

Objectives ............................................................................................................................... 26

Annotation Guidelines for Tagging Entities:................................................................28Disease/ Disorder................................................................................................................................ 28Signs/ Symptoms.................................................................................................................................. 30Procedure............................................................................................................................................... 32Outcome.................................................................................................................................................. 34DOA (Date of Admission)................................................................................................................... 34DOD (Date of Dsicharge/ Death).....................................................................................................35

Annotation Guidelines for Entity Attributes................................................................35Negation.................................................................................................................................................. 36Speculation............................................................................................................................................. 36Co-Morbidity.......................................................................................................................................... 37

Annotation Guidelines for Tagging Events....................................................................37Age............................................................................................................................................................ 37Referred_From...................................................................................................................................... 38Timex....................................................................................................................................................... 38Duration.................................................................................................................................................. 38Severity_Severe .................................................................................................................................... 39Severity_Moderate............................................................................................................................... 39Severety_Mild........................................................................................................................................ 39Progression_Improved/ Progression_Worsened......................................................................40Body_Part................................................................................................................................................ 40Laterality................................................................................................................................................. 41Lab_Value................................................................................................................................................ 42

1? Last edited and reviewed on 02/02/2014

OverviewBelow are some broad guidelines that we developed and followed while annotating the critical care discharge summaries for training the Cocoa/ Peaberry system. In some cases, the guidelines are specific to the institutions where the annotations were performed due to the structure of the discharge summaries. Please feel free to adapt them to suit the requirements of your institution. The annotations were performed using the brat rapid annotation tool v1.3, which is an Open Source web-based tool for text annotation.

Use the link below to learn more about brat and to download it.http://brat.nlplab.org/

Objectives

The goal of this task is to review the critical care discharge summaries and annotate key-parameters. The task consists of two distinct steps:

1. Identifying key parameters within a certain span of clinical text2. Annotate and normalize the parameters

All annotations will be based on two major categories:1. Entity Type2. Event Type

The following parameters are listed as “Entity Types”:1. Disease/ Disorder2. Sign/ Symptom3. Procedure4. Outcome5. DOA (Date of Admission)6. DOD (Date of Discharge)7. Lab_Parameter

These entity types are associated with the following attributes:a) Negationb) Speculationc) Co-morbidity

The following parameters are listed as “Event Types”:1. Age2. Sex3. Referred_from4. Timex5. Duration6. Severity_Mild7. Severity_Moderate

8. Severity_Severe9. Progression_Improved10. Progression_Worsened11. Body_part12. Laterality13. Lab_Value

An example that shows all the Entity, Event types and Attributes configured on our version of brat can be seen in the figure below.

Figure 1: Entity, Events and Attributes configured on brat

Annotation Guidelines for Tagging Entities:

Disease/ DisorderTypically, all clinical diagnoses made on the patient qualifies to be tagged as a disease/ disorder. Ideally, the diagnoses, when looked up on any standard SNOMED-CT browser must be mapped to the concept “disorder”. It can include complete names, abbreviations and short names. E.g. intracranial bleeding, intracranial hemorrhage, IC bleed, tibial fracture, pleural effusion, etc.

e.g. “Multi organ Dysfunction Syndrome”e.g. “Acute exacerbation of Bronchial Asthma”e.g. “Chronic Kidney Disease”e.g. “Septic Shock”

One can also annotate and associate events to the disease/ disorder entity.

e.g. “Severe decompensated liver disease”. In this case, while “liver disease” is a disease/ disorder (also a possible co-morbidity), “decompensated” can be tagged as Progression_Worsened (by definition, decompensation is a progressive deterioration from a normal physiological state) and “severe” can be tagged as Severity_Severe.

Figure 2: Note the event type "decompensated" tagged as Progression_Worsened linked via a theme to the disease/ disorder "liver disease". Also note the disease mentions "hypertension" and "type 2 diabetes" tagged as disease/ disorder with the co-morbidity

If lab findings such as hyponatremia, hyperkalemia, hypomagnesemia are present within the diagnosis section, tag them as disease/ disorder. If they are present within the course in ICU, tag them as signs/ symptoms.

e.g. Final diagnosis 1. Hyponatremia, 2. Metabolic encephalopathy. In this case, tag the entities as disease/ disorder.

e.g. “Investigations revealed hyponatremia and hypomagnesemia”. In this case, tag the entities as sign/ symptom.

Another example would be disjointed entities such as “fracture of the left tibia”. Although this is a clinical diagnosis, this phrase is best annotated by means of dissection such as “fracture” will be a disease/ disorder, “left” as laterality and “tibia” will be tagged as the body_part.

In some cases, the sign can also be labeled as the diagnosis. A good example would be “pleural effusion” whether this is tagged as a sign/ symptom or as a disease/ disorder is based on the context of the appearance of this phrase. If “pleural effusion” is mentioned under the header “diagnosis” this will be tagged as a disease/ disorder. If this appears under examination findings or under procedure-CXR it should be tagged as a sign/ symptom.

What should not be annotated: symptoms and signs cannot be included. E.g fever, pallor, raised intracranial tension and so forth.

Signs/ SymptomsAll clinically relevant signs and symptoms will be tagged so. E.g. fever, breathlessness, chest pain, vomiting and so forth. The general rule to follow in case of confusion is to look-up the SNOMED CT browser and look for the specific term in question. If the results return the term as a “finding” (within the fully specified name of the clinical concept), it can be tagged as a sign/ symptom.

There can also occur negation attributes to sign/ symptoms such as “no murmurs”, “no focal neurological deficits”, “no h/o hypertension” and so forth. In such cases, tag the clinical entity with a negation attribute. This has been explained in detail in the section on Negation below.

Examples of sign/ symptom

e.g. “patient presented with fever, breathlessness, headache and vomiting since the past 3 days”e.g. “on examination patient was found to be hypotensive”e.g. “CXR: Pleural effusion of the left lower zone”e.g. “echo: mild MR, mild TR”e.g. “ECG: Sinus tachycardia, T wave inversion”e.g. GCS E6M6V2 (tag all GCS occurrences irrespective of scores)e.g. "Patient had fresh ECG changes with elevated Trop I levels"e.g. “Patient had distinct ECG changes”

Special note: In case of phrases such as “no breath sounds were heard”, “no heart sounds on auscultation”, DO NOT tag “breath sounds” or “heart sounds” as a SS with a negation. The fact that there were no heart sounds is itself a symptom.

Note:

If lab findings such as hyponatremia, hyperkalemia, hypomagnesemia are present within the diagnosis section, tag them as disease/ disorder. If they are present within the course in ICU, tag them as signs/ symptoms.

e.g. Final diagnosis 1. Hyponatremia, 2. Metabolic encephalopathy

e.g. “Investigations revealed hyponatremia and hypomagnesemia”. In this case, tag the entities as sign/ symptom.

Outside “Final Diagnosis” Cardiac/cardiopulmonary arrest is tagged as signs_symptoms.

In the phrase, “Left Lower lobe consolidation” tag “left” as laterality and “lower lobe con-solidation” as the sign_symptom. This follows the same rule as annotation of body_part in disease/ disorder (non-disjointed entity).

In the phrase “fracture left humerus”, tag “fracture” as the sign/ symptom. Add a Fragment to include “humerus”. Tag “left” as laterality

Smoker/history of smoking could be annotated as sign/symptom (It is a finding in SNOMED CT)

History of alcohol consumption could be annotated as sign/symptom (It is a finding in SNOMED CT)

While annotating signs and symptoms in procedures such as ECG, Echo, U/S, etc, please annotate only the positive findings. DO NOT tag normal findings.e.g. 1.“Echo: mild MR, mild TR, apex hypokinetic, EF 60%”e.g. 2.“Echo: mild MR, mild TR, apex hypokinetic, EF 40%”e.g.3. “PASP 45”In e.g.1, everything except EF 60% must be tagged as they represent abnormal findings. In this guideline we are considering an EF of 50% and above as a normal finding. Likewise, in e.g.2, EF 40% must be tagged as it is an abnormal finding. In e.g.3, it is important to only tag PASP that is >30 (denotes PAH)

Only tag signs and symptoms that are abnormal in Procedures. Normal findings can be ignored.e.g. “Echo: Poor window, normal valves, conc.LVH, no RWMA, IVC dilated, EF 50%, No clot or vegetation”

What should not be annotated: In some cases, the sign can also be factually labeled as a diagnosis. A good example would be “pleural effusion” whether this is tagged as a sign/ symptom or as a disease/ disorder is based on the context of the appearance of this phrase. If “pleural effusion” is mentioned under the header “diagnosis” this will be tagged as a disease/ disorder. If this appears under examination findings or under procedure-CXR it should be tagged as a sign/ symptom.Another example is “Multiple ulcers” and “Multiple Myeloma”. Do not tag “multiple” as severity. Instead, tag the entire phrase as a SS. This follows the same rule as non-disjointed entities.

Any normal signs/ symptoms such as “soft”, “afebrile”, “sinus rhythm”, etc must be excluded except when it occurs with a prefix such as “no fever” (in which case it becomes a negative attribute of a symptom).

Pupil sizes not to be annotated. Only abnormal pupil reactions to be annotated as SS.e.g.1. Pupil – 2mm (do not annotate)e.g.2. Pupils sluggish

ProcedureAll invasive and non-invasive procedures performed during hospital stay will be tagged as a procedure. E.g. tracheostomy, CPR, ventilation, intubation and so forth. The scope also includes investigative procedures such as CXR, U/S, CT and MRI. If any doubt, look-up ICD-10 procedure codes or

SNOMED CT online.

e.g. “patient was intubated and mechanically ventilated”

e.g. “b/l carotid and vertebral Doppler was done” (in this case “carotid” and “Doppler” must be connected with a fragment because both carotid Doppler and vertebral Doppler are names of procedures.

Special Note: The non-disjointed entity rule will apply for procedures as well. e.g 1. “cervical traction was applied”. In this case, “cervical traction” will be tagged as the procedure.

e.g 2. “right eye cataract surgery”. In this case, “eye cataract surgery” will be tagged as the procedure and “right” as laterality (although cataract surgery implies that the procedure was done on the eye, for the sake of consistency, it will have to follow the non-disjointed entity rule).

e.g. 3. “external pelvic compression was performed to stop bleeding”. “external pelvic compression” is the procedure that needs to be tagged.

e.g. 4. “carotid and vertebral artery Doppler”. In this case, “vertebral artery Doppler” will be tagged as the first procedure while “Doppler” will be tagged as the second procedure along with “carotid” and “artery” (linked by a fragment) will be the BP linked via a theme to Doppler.

Any procedure named with the prefix “status post” or “s/p” or “h/o” or any other synonym that indicates that the procedure was performed earlier must be tagged as a TIMEX component E.g. “s/p laparotomy”, where laparotomy is tagged as a procedure, “s/p” is tagged as TIMEX and linked to the procedure via a theme.

Figure 3: Tagging Timex via themes to procedures

Also, if the date of previous surgery is known in which case the procedure must be tagged and the date must be tagged as a Timex component and linked via a theme.

e.g. “tracheostomy was performed on 22/11/2013”

Exclusions: Only in cases where investigative procedures are associated with body parts, it is important to tag the anatomical structure and the procedure separately and link them via a theme.

e.g. 1. Abdominal U/S – Abdominal = BP and U/S = proceduree.g. 2. CT head or MRI brain – CT = procedure and head = BP (likewise for MRI)e.g. 3. Carotid and vertebral Doppler – Carotid and Vertebral = BP and Doppler = procedure

What needs to be excluded: Minor procedures such as IV line insertion, parenteral antibiotics, blood transfusion, etc must be excluded.

All planned procedures such as “tracheostomy was planned” , “initially wanted to do dialysis”, must be excluded.

Also, we chose not to tag “fluid resuscitation” as a procedure.

OutcomeClinical outcomes such as “dead”, “death”, “could not be revived”, “DNR”, “DNI”, “succumbed”,

“discharged”, “comfort care”, “discharged against medical advice”, “DAMA”, etc, have to be annotated. If multiple outcomes are present in the summary, all of them need to be annotated.

e.g. 3 cycles of CPR was given but patient could not be revived. Patient was declared dead at XXX hrs.

e.g. patient’s relatives wanted to withdraw life support.

e.g. patient was revived after 2 cycles of CPR however his condition continued to deteriorate. Patient went into asystole and was declared dead at xxx hrs.

What should not be annotated: Intermediate outcomes should not be annotated.

e.g. “patient was initially revived with 3 cycles of DC shock. However patient succumbed as regular rhythm could not be obtained”In the above example, there are two outcomes that are present. The first is an intermediate outcome wherein the patient was revived with resuscitation, however, the end outcome was death. We are interested in only capturing the end outcomes and not the intermediate ones.

DOA (Date of Admission)This is usually found at the beginning of the discharge summary. Only the words “DOA”, “Date of Admission” or any other term that signifies entry of the patient within the hospital must be tagged. DOA must always be linked to the event type TIMEX via a theme. The Timex component will usually appear in a dd/mm/yy or dd/mm/yyyy format.

e.g. DOA: 11/12/2014 where DOA is tagged as DOA and 11/12/2014 will be tagged as the Timex component

What should not be tagged: Do not Tag any phrase that corresponds to date of admission anywhere else within the document after the DOA has been tagged in the beginning. DOA should be tagged ONLY ONCE.

e.g. “DOA: 22/07/2007”….”Patient was admitted to XXX hospital on 22/07/2007 with c/o…”In this example, only tag DOA as DOA and 22/07/2007 as the Timex component and link them with a theme. DO NOT tag “admitted on” and the subsequent date component.

Do not tag dates of admission to any other hospitals in the past.e.g. “on 10/02/2013, patient was admitted to XXX”

DOD (Date of Dsicharge/ Death)This is usually found at the beginning of the discharge summary. Only the words “DOD”, “Date of Discharge”, “Date of Death” or any other term that signifies exit of the patient from the hospital must be tagged. DOD must always be linked to the event type TIMEX via a theme. The Timex component will usually appear in a dd/mm/yy or dd/mm/yyyy format.

e.g. DOD: 11/12/2014 where DOD is tagged as DOD and 11/12/2014 will be tagged as the Timex component

e.g. DAMA: 13/04/13, where DAMA is tagged as DOD and 13/04/13 is the Timex component.

Do not Tag any phrase that corresponds to date of discharge or death anywhere within the document after the DOD has been tagged in the beginning. DOD should be tagged ONLY ONCE.

Lab_ParameterAny laboratory investigation (except radiological ones such as x ray, CT, etc) will qualify as Lab_Parameter. Most biochemical, Microbiological, hematological and histopathological examinations would be part of this. All discharge summaries have a dedicated investigations section where they can be found. This will mostly be pre-seeded from a script prior to annotations. However, If not seeded, tag the relevant test names as Lab_Parameter. Tag these entities even if they are found outside the lab investigations section of the discharge summaries.

e.g. K+, TLC, Hb, ESR, Blood C/S, CSF C/S, Lac, HCO3, Platelets, etc

Figure 4: Annotating lab_value and lab_parameter

Annotation Guidelines for Entity Attributes

NegationThis signifies the absence of either a disease/ disorder or a sign/ symptom.

e.g. CVS: S1S2 heard, no murmurs. In this case, the word “murmurs” has been tagged as a sign/ symptom while also selecting the ‘negation’ attribute. COCOA will do a contextual analyses to understand that the prefix “no” assigns a negative attribute to the entity.e.g. no h/o hypertension

Figure 5: Annotating negation attributes

It must be remembered that all normal findings such as “no focal neurological deficits”, “no organomegaly”, “no fever” must also be tagged as it represents absence of disease.

This also applies to procedures such as CT/ MRI, echo, Doppler or ultrasound where phrases such as

“no PE/ clot/ vegetation”, “no RWMA” and “no MR/ TR” or “no flow observed” are quite common. In all these cases, it is important to tag the SS with a negation as they also represent absence of disease.

What not to include: words or phrases that are actually abnormal findings with the “no” prefix. e.g. “no breath sounds were heard” – in this case, tag “no breath sounds” as the SS.

The negation attribute must not be annotated for other entities such as procedures and outcomes.

SpeculationThis is to be applied to only disease/ disorder and sign/ symptoms. This signifies a certain indecisiveness and that the clinical concept is open to a query. This attribute is to be tagged whenever it is associated with the symbol “?” either as a prefix or suffix to the clinical term or when associated with words such as “suspect”, “suspected”, “suspicion”, “query”, “possible” (possible radiation pneumonitis), “could suggest” (presence of nodules could suggest PTB), etc. In all such cases, the clinical term must be tagged either as a disease/ disorder or as a sign/ symptom along with the speculation attribute selected.

e.g. ?? enteric fever

e.g. lupus??

e.g. clinical suspicion of typhoid fever

e.g. peripheral smear sent to rule out malaria

What not to include: “consistent with” is not a speculation. It is rather a confirmation of the findings.e.g. "CT angiogram on 5/12/2024 showed features consistent with fat embolism"

Co-MorbidityThis only applies to the disease/ disorder entity. A term must be linked to this attribute only if the patient has a known history of any disease.

Newly diagnosed conditions should not be tagged with this attribute.

e.g. of what should be tagged “patient is a k/c/ o hypertension and type 2 diabetes”

e.g. “old case of pulmonary TB”

e.g. of what should not be tagged “newly diagnosed case of hyperthyroidism”.

Annotation Guidelines for Tagging Events

AgeTag not only the numbers but also the units besides it. This can be found within the patient demographics section at the very top of the discharge summary.

e.g. Age: 29 years

e.g. Age: 1 year and 8 months

Sex: This signifies the phenotypic gender of the patient.

e.g. Sex: Malee.g. Sex: Femalee.g. Sex: Me.g. Sex: Fe.g. Sex: other/ Transgender

Referred_FromThis must be annotated in order for COCOA to identify the healthcare facility from where the patient was referred from. The facility could be an external entity or it could be departments within the same medical facility where the patient is admitted. It’s important to tag all the locations from where the patient was referred.

e.g. “the patient presented to emed with c/o chest pain”

e.g. “patient sustained burns and was taken to hospital HHH1 where after initial first aid was shifted to HHH. Thereafter patient was admitted in burns ward…”

e.g. “patient was taken to emed at xxx hospital on 22/11/2011 and thereafter referred to HHH on 23/11/2011” (Do not tag HHH as a referred_from location as it represents the hospital to which the patient was referred to)

Note: HHH=final destination hospitalHHH1=First referral hospitalHHH2=Second referral hospital

Examples of referred_from include, emed, emergency medicine dept, emergency medicine department, burns ward, surgical ITU, Neuro ITU, MITU, Nephrology ward HHH1, HHH2 and so forth.

TimexThis component must be tagged every time that there is a reference of a temporal component. Most commonly, these are dates of importance. While tagging them, they must always be linked to entities such as DOA, DOD, Procedure, disease, symptom, etc.

e.g. “Patient underwent cholecystectomy on 11/08/09”. In this case, do remember to tag the procedure “cholecystectomy” to the procedure date with via a theme.

e.g. “DOA: 11/11/11”

e.g. “patient was referred to xxx hospital on 11/11/11”

DurationThis marks the period which signifies start of symptoms.

e.g. “patient presented with breathlessness since the past 3 days”

e.g. “h/o LoC for 2-3 min”

e.g. “patient was diagnosed with TB 10 yrs back”

Severity_Severe This signifies the severity of symptoms. Severe must be ascribed to the worst ever possible grade of symptom/ sign/ disorder. This must always be linked via a theme to an entity such as signs/ symptoms. Typical examples of qualifiers for severity severe include “severe”, “excruciating”, “unbearable”, “copious”, “extensive”, “uncontrolled”, “plenty”, “large”, “refractory”, “etc

e.g. “ABG showed severe metabolic acidosis”e.g. “USG Abdomen: gross ascites”e.g. “Extensive pulmonary edema”e.g. “gross hematuria”

Severity_ModerateThis signifies the severity of symptoms. Moderate must be ascribed to a medium grade of symptom/ sign/ disorder. This must always be linked via a theme to an entity such as signs/ symptoms. Typical examples of qualifiers for severity moderate include “moderate”, “mod-severe”, etc.

e.g. “echo: moderate grade MR”

Severety_MildThis signifies the severity of symptoms. Mild must be ascribed to a low grade of symptom/ sign/ disorder. This must always be linked via a theme to an entity such as signs/ symptoms. Typical examples of qualifiers for severity severe include “mild”, “occasional”, “minimal”, “small”, etc.

e.g. “mild tenderness in right upper quadrant of the abdomen”e.g. “occasional ronchi in right upper lobe”

Common Note (1): The severity grading must not be used for describing acute events such as acute respiratory distress, acute appendicitis, etc.

Common Note (2): Do not tag stage/ grade of diseases to severity. e.g. CKD Stage 4, breathlessness grade 2, etc

Common Note (3): Do not tag ++ or +++ as severity, club it with the sign as Sign_symptom. Eg. Pallor ++ tagged as Sign_symptom

Common Note (4): The words “multiple” and “scattered” need to be treated as non-disjointed entities. E.g. scattered ronchi, multiple ulcers (tag the entire phrase as SS)

Common Note (5): Do not tag “impending” as an attributee.g. “impending respiratory failure”, Tag only

Progression_Improved/ Progression_WorsenedThis tag denotes the progress of the symptom or disease entity. The progression event type must be linked to either a sign/ symptom or disease/ disorder.

e.g. (Progression_Worsened) “developed sudden onset headache with deterioration of GCS”. Words suggestive of progression_worsened include “worsened”, “deteriorated”, “decompensated”, “worsening”, “complicated” (complicated malaria), “increase”, “increased”, “increasing” (patient presented with increasing abdominal distension), “declined”, etc.

e.g. (Progression_Improved) “liver functions returned to normal on day 2 of ICU admission”Words suggestive of progression_improved include, “resolved”, “resolving”, “improved”, “recovered”, and “corrected”.

Common Note: Do not tag Progression as an independent event. It always has to be associated with an En-

tity such as a disease/ disorder or sign/ symptom.e.g. Patient’s condition continued to worsen (do not tag worsen as progression event)

Also, in cases such as “hypoxia did not improve/ did not resolve”, do not tag the word “not improve” or “resolved” as the condition represents status quo.

In cases where a particular status of a condition has been mentioned as “resolved”, tag the word “resolved” as “Progression_Improved”e.g. “ARDS Resolved”, “She had one episode of tachycardia and hypotension which re-solved”

Body_PartThis event type must be tagged every time that a mention of an anatomical location is made. This must always be linked with a theme to either a relevant entity or another event.

e.g. “fracture of left tibia”

e.g. “GPE: Abdomen – Distended”

e.g. “burns sustained to both upperlimbs”

e.g. “bleeding PV present with passage of clots” (in this case “PV” is the anatomical location and “clots” is the clinical sign).

e.g. “pupils b/l fixed and non-reactive”

When should it not be tagged: Whenever the anatomical location is part of the sign or disease/ disorder.

e.g. “Left Tibial Fracture” in this case the phrase “Tibial Fracture” gets annotated as a disease/ disorder. “Left” will be tagged as laterality.

Other obvious examples include situations such as “Abdomen examination: Liver Enlarged”. In this case, there is no necessity to tag abdomen as it is understood that the liver is part of the abdominal cavity.

Also, not to tag body_part if the finding is normal.e.g. Abdomen: softe.g. pupils b/l equal and reactive

Note: Do not tag ECG leads as body_part

Few more examples of non-disjointed and disjointed entities that you can come across:1. BP SS and SS

e.g. “abdominal distension and tenderness”; where, abdominal distension to be tagged as a single SS entity, while tenderness to be tagged as a separate SS entity with “abdominal” tagged as a fragment.

2. BP and BP SSe.g.1. "mesenteric and renal artery infarcts"; where, “renal artery infarcts” to be tagged as the first SS while “infarcts” will be the second SS with a fragment attached to “mesenteric” and “artery” as the BP.e.g.2. "right upper and lower extremity weakness"; where, “right” is the laterality, “lower extremity weakness” is the first SS while “weakness” tagged as the second SS along with “upper” and “extremity” (connected by fragments) as BP.

3. BP: SS and SSe.g.“Abdomen: Guarding and Rigidity” Abdomen=BP, Guarding=SS, Tenderness=SS. Ab-domen to be linked to both SS via a theme.

LateralityBesides the anatomical location. It is also important to identify the side where the disease/ symptom has occurred. Typical examples of words that need to be tagged include “right”, “left”, “b/l”, “Rt”, “Lt”. Laterality must also be linked to the body_part or disease/ disorder or sign/ symptom or procedure via a theme.

e.g. “burns sustained to both upperlimbs”e.g. “bilateral decreased air entry”e.g. “ruptured left posterior communicating aneurysm with extensive SAH”

Lab_ValueAny values associated with the lab parameters qualify to be tagged as Lab_Value. This must be linked to the Lab_Parameter via a theme (see Figure 2).

As a general rule, lab parameters and values mostly occur in their appropriate sections. However, in some cases, they can appear in other sections like “Final Diagnosis” and “Course in ICU”.

e.g. If the statement HRV positive status is found in the Diagnosis section, then it would get annotated as diagnosis. On the other hand in a statement like “lab tests revealed that the patient was HIV positive”, HIV would be tagged as Lab_Parameter and positive as Lab_Value.

e.g. Ca2+ 8.6e.g. hb 12.0e.g. Platelets 1.2 or Platelets 250,000e.g. Blood c/s: Staph aureus or Blood c/s: no growthM.P nege.g. HBsAg –vee.g. HRV pos

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