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Clinical documentation

Clinical documentation has been a cornerstone of medical care for hundreds of years, if not longer 1).

The products of such documentation, conventionally called “notes,” serve many purposes: reminding the note author of what they did, communicating to other providers both in the present and the future, justifying a level of service provided and fee charged, defending decisions in case of malpractice accusations, providing data for research and quality improvement, and even communicating with patients as in OpenNotes 2) 3) 4).

The last major paradigm shift in documentation occurred in 1968 when Dr. Larry Weed proposed the problem-oriented medical record 5).

Weed presaged and welcomed electronic health records (EHRs) 6), writing that “it can readily be seen that … in the future all narrative data may be entered through [a] series of displays.

Clinical documentation is usually stored in an unstructured format in electronic health records (EHR). Processing the information is inconvenient and time-consuming and should be enhanced by computer systems. In this paper, a rule-based method is introduced that identifies adverse events documented in the EHR that occurred during treatment. For this purpose, clinical documents are transformed into a semantic structure from which adverse events are extracted. The method is evaluated in a user study with neurosurgeons. In comparison to a bag of word classification using support vector machines, our approach achieved comparably good results of 65% recall and 78% precision. In conclusion, the rule-based method generates promising results that can support physicians' decision making. Because of the structured format the data can be reused for other purposes as well 7).

Gillum RF. From papyrus to the electronic tablet: A brief history of the clinical medical record with lessons for the digital age. Am J Med. 2013;126:853–857.
Delbanco T, Walker J, Darer JD, et al. Open notes: Doctors and patients signing on. Ann Intern Med. 2010;153:121–125.
Wolff JL, Darer JD, Berger A, et al. Inviting patients and care partners to read doctors’ notes: OpenNotes and shared access to electronic medical records. J Am Med Inform Assoc. 2017;24(e1):e166–e172.
Bell SK, Mejilla R, Anselmo M, et al. When doctors share visit notes with patients: A study of patient and doctor perceptions of documentation errors, safety opportunities and the patient–doctor relationship. BMJ Qual Saf. 2017;26:262–270.
Weed LL. Medical records that guide and teach. N Engl J Med. 1968 Mar 14;278(11):593-600. PubMed PMID: 5637758.
Slack WV, Hicks GP, Reed CE, Van Cura LJ. A computer-based medical-history system. N Engl J Med. 1966;274:194–198
Gaebel J, Kolter T, Arlt F, Denecke K. Extraction Of Adverse Events From Clinical Documents To Support Decision Making Using Semantic Preprocessing. Stud Health Technol Inform. 2015;216:1030. PubMed PMID: 26262330.
clinical_documentation.txt · Last modified: 2019/09/10 21:00 by administrador