AIMC Topic: Documentation
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Efficiency and Quality of Generative AI-Assisted Radiograph Reporting.
JAMA network open
Jun 2, 2025
IMPORTANCE: Diagnostic imaging interpretation involves distilling multimodal clinical information into text form, a task well-suited to augmentation by generative artificial intelligence (AI). However, to our knowledge, impacts of AI-based draft radi...
Exploring Suitability of Low-Severity Rating Hospital Incident Reports for Machine Learning.
Computers, informatics, nursing : CIN
May 1, 2025
Electronic incident reporting is a key quality and a safety process for healthcare organizations that assists in evaluating performance and informing quality improvement initiatives. Although it is mandatory for high-severity incident reports to be i...
Artificial intelligence based assessment of clinical reasoning documentation: an observational study of the impact of the clinical learning environment on resident documentation quality.
BMC medical education
Apr 22, 2025
BACKGROUND: Objective measures and large datasets are needed to determine aspects of the Clinical Learning Environment (CLE) impacting the essential skill of clinical reasoning documentation. Artificial Intelligence (AI) offers a solution. Here, the ...
Enhancing Accuracy of Operative Reports with Automated Artificial Intelligence Analysis of Surgical Video.
Journal of the American College of Surgeons
Apr 16, 2025
BACKGROUND: The creation of operative reports is a tedious documentation task that increases administrative burden, which is a potential driver of burnout. Additionally, operative reports are inherently subjective and may contain inaccuracies and inc...
Assessing Patient-Reported Satisfaction With Care and Documentation Time in Primary Care Through AI-Driven Automatic Clinical Note Generation: Protocol for a Proof-of-Concept Study.
JMIR research protocols
Apr 7, 2025
BACKGROUND: Relisten is an artificial intelligence (AI)-based software developed by Recog Analytics that improves patient care by facilitating more natural interactions between health care professionals and patients. This tool extracts relevant infor...
Identifying Patient-Reported Outcome Measure Documentation in Veterans Health Administration Chiropractic Clinic Notes: Natural Language Processing Analysis.
JMIR medical informatics
Apr 2, 2025
BACKGROUND: The use of patient-reported outcome measures (PROMs) is an expected component of high-quality, measurement-based chiropractic care. The largest health care system offering integrated chiropractic care is the Veterans Health Administration...
Artificial Intelligence (AI) - Powered Documentation Systems in Healthcare: A Systematic Review.
Journal of medical systems
Feb 18, 2025
Artificial Intelligence (AI) driven documentation systems are positioned to enhance documentation efficiency and reduce documentation burden in the healthcare setting. The administrative burden associated with clinical documentation has been identifi...
Clinician Experiences With Ambient Scribe Technology to Assist With Documentation Burden and Efficiency.
JAMA network open
Feb 3, 2025
IMPORTANCE: Timely evaluation of ambient scribing technology is warranted to assess whether this technology can lessen the burden of clinical documentation on clinicians.
Accuracy and Safety of AI-Enabled Scribe Technology: Instrument Validation Study.
Journal of medical Internet research
Jan 27, 2025
Artificial intelligence-enabled ambient digital scribes may have many potential benefits, yet results from our study indicate that there are errors that must be evaluated to mitigate safety risks.
Assessment of Real-Time Natural Language Processing for Improving Diagnostic Specificity: A Prospective, Crossover Exploratory Study.
Applied clinical informatics
Jan 8, 2025
BACKGROUND: Reliable, precise, timely, and clear documentation of diagnoses is difficult. Poor specificity or the absence of diagnostic documentation can lead to decreased revenue and increased payor denials, audits, and queries to providers. Nuance...
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