AIMC Topic: Documentation

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A Method to Improve Availability and Quality of Patient Race Data in an Electronic Health Record System.

Applied clinical informatics
BACKGROUND: Although federal regulations mandate documentation of structured race data according to Office of Management and Budget (OMB) categories in electronic health record (EHR) systems, many institutions have reported gaps in EHR race data that...

The Utility of Clinical Notes for Sexual Minority Health Research.

American journal of preventive medicine
INTRODUCTION: Despite improvements in electronic medical record capability to collect data on sexual orientation, not all healthcare systems have adopted this practice. This can limit the usability of systemwide electronic medical record data for sex...

Regional Variations in Documentation of Sexual Trauma Concepts in Electronic Medical Records in the United States Veterans Health Administration.

AMIA ... Annual Symposium proceedings. AMIA Symposium
Experiences of sexual trauma are associated with adverse patient and health system outcomes, but are not systematically documented in electronic health records (EHR). To describe variations in how sexual trauma is documented in the Veterans Health ...

Deep Natural Language Processing Identifies Variation in Care Preference Documentation.

Journal of pain and symptom management
CONTEXT: Documentation of care preferences within 48 hours of admission to an intensive care unit (ICU) is a National Quality Forum-endorsed quality metric for older adults. Care preferences are poorly captured by administrative data.

Unsupervised Machine Learning of Topics Documented by Nurses about Hospitalized Patients Prior to a Rapid-Response Event.

Applied clinical informatics
BACKGROUND: In the hospital setting, it is crucial to identify patients at risk for deterioration before it fully develops, so providers can respond rapidly to reverse the deterioration. Rapid response (RR) activation criteria include a subjective co...

Extractive single document summarization using binary differential evolution: Optimization of different sentence quality measures.

PloS one
With the increase in the amount of text information in different real-life applications, automatic text-summarization systems become more predominant in extracting relevant information. In the current study, we formulated the problem of extractive te...

Exploring Large-scale Public Medical Image Datasets.

Academic radiology
RATIONALE AND OBJECTIVES: Medical artificial intelligence systems are dependent on well characterized large-scale datasets. Recently released public datasets have been of great interest to the field, but pose specific challenges due to the disconnect...

Improving documentation of presenting problems in the emergency department using a domain-specific ontology and machine learning-driven user interfaces.

International journal of medical informatics
OBJECTIVES: To determine the effect of a domain-specific ontology and machine learning-driven user interfaces on the efficiency and quality of documentation of presenting problems (chief complaints) in the emergency department (ED).

Documentation of Palliative and End-of-Life Care Process Measures Among Young Adults Who Died of Cancer: A Natural Language Processing Approach.

Journal of adolescent and young adult oncology
Few studies have investigated palliative and end-of-life care processes among young adults (YAs), aged 18-34 years, who died of cancer. This retrospective study used a natural language processing algorithm to identify documentation and timing of four...