AIMC Topic: Documentation

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Artificial intelligence for better goals of care documentation.

BMJ supportive & palliative care
OBJECTIVES: Lower rates of goals of care (GOC) conversations have been observed in non-white hospitalised patients, which may contribute to racial disparities in end-of-life care. We aimed to assess how a targeted initiative to increase GOC documenta...

Assessing the Efficacy and Clinical Utility of Artificial Intelligence Scribes in Urology.

Urology
OBJECTIVE: To assess the quality of artificial intelligence (AI) scribes and to evaluate their impact on urologic practice.

Extracting International Classification of Diseases Codes from Clinical Documentation Using Large Language Models.

Applied clinical informatics
BACKGROUND:  Large language models (LLMs) have shown promise in various professional fields, including medicine and law. However, their performance in highly specialized tasks, such as extracting ICD-10-CM codes from patient notes, remains underexplo...

Large Language Models to Identify Advance Care Planning in Patients With Advanced Cancer.

Journal of pain and symptom management
CONTEXT: Efficiently tracking Advance Care Planning (ACP) documentation in electronic heath records (EHRs) is essential for quality improvement and research efforts. The use of large language models (LLMs) offers a novel approach to this task.

Natural Language Processing of Clinical Documentation to Assess Functional Status in Patients With Heart Failure.

JAMA network open
IMPORTANCE: Serial functional status assessments are critical to heart failure (HF) management but are often described narratively in documentation, limiting their use in quality improvement or patient selection for clinical trials.

Large language models for structured reporting in radiology: past, present, and future.

European radiology
Structured reporting (SR) has long been a goal in radiology to standardize and improve the quality of radiology reports. Despite evidence that SR reduces errors, enhances comprehensiveness, and increases adherence to guidelines, its widespread adopti...

The Impact of Collaborative Documentation on Person-Centered Care: Textual Analysis of Clinical Notes.

JMIR medical informatics
BACKGROUND: Collaborative documentation (CD) is a behavioral health practice involving shared writing of clinic visit notes by providers and consumers. Despite widespread dissemination of CD, research on its effectiveness or impact on person-centered...

Machine Learning for Targeted Advance Care Planning in Cancer Patients: A Quality Improvement Study.

Journal of pain and symptom management
CONTEXT: Prognostication challenges contribute to delays in advance care planning (ACP) for patients with cancer near the end of life (EOL).

Bridging the Gap: Can Large Language Models Match Human Expertise in Writing Neurosurgical Operative Notes?

World neurosurgery
BACKGROUND: Proper documentation is essential for patient care. The popularity of artificial intelligence (AI) offers the potential for improvements in neurosurgical note-writing. This study aimed to assess how AI can optimize documentation in neuros...