| Development and evaluation of a clinical note section header terminology. | |
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MedLine Citation:
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PMID: 18999303 Owner: NLM Status: MEDLINE |
Abstract/OtherAbstract:
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Clinical documentation is often expressed in natural language text, yet providers often use common organizations that segment these notes in sections, such as history of present illness or physical examination. We developed a hierarchical section header terminology, supporting mappings to LOINC and other vocabularies; it contained 1109 concepts and 4332 synonyms. Physicians evaluated it compared to LOINC and the Evaluation and Management billing schema using a randomly selected corpus of history and physical notes. Evaluated documents contained a median of 54 sections and 27 major sections. There were 16,196 total sections in the evaluation note corpus. The terminology contained 99.9% of the clinical sections; LOINC matched 77% of section header concepts and 20% of section header strings in those documents. The section terminology may enable better clinical note understanding and interoperability. Future development and integration into natural language processing systems is needed. |
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Authors:
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Joshua C Denny; Randolph A Miller; Kevin B Johnson; Anderson Spickard |
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Publication Detail:
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Type: Evaluation Studies; Journal Article; Research Support, U.S. Gov't, P.H.S. Date: 2008-11-06 |
Journal Detail:
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Title: AMIA ... Annual Symposium proceedings / AMIA Symposium. AMIA Symposium Volume: - ISSN: 1942-597X ISO Abbreviation: - Publication Date: 2008 |
Date Detail:
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Created Date: 2008-11-12 Completed Date: 2010-01-08 Revised Date: - |
Medline Journal Info:
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Nlm Unique ID: 101209213 Medline TA: AMIA Annu Symp Proc Country: United States |
Other Details:
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Languages: eng Pagination: 156-60 Citation Subset: IM |
Affiliation:
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Vanderbilt University School of Medicine, Nashville, TN, USA. |
Export Citation:
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| MeSH Terms | |
Descriptor/Qualifier:
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Artificial Intelligence* Medical History Taking / methods* Natural Language Processing* Tennessee Terminology as Topic* Vocabulary, Controlled* Writing* |
| Grant Support | |
ID/Acronym/Agency:
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R01 LM007995/LM/NLM NIH HHS; R21 CA116573/CA/NCI NIH HHS; T15 LM007450/LM/NLM NIH HHS |
| Comments/Corrections | |
From MEDLINE®/PubMed®, a database of the U.S. National Library of Medicine
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