Extracting diagnoses from discharge summaries

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Updated: Aug 7, 2026

A Metadata Extraction Approach for Clinical Case Reports to Enable Advanced Understanding of Biomedical Concepts
07:50

A Metadata Extraction Approach for Clinical Case Reports to Enable Advanced Understanding of Biomedical Concepts

Published on: September 20, 2018

William Long1

  • 1CSAIL, Massachusetts Institute of Technology, Cambridge, MA, USA.

AMIA ... Annual Symposium Proceedings. AMIA Symposium
|June 17, 2006
PubMed

Related Concept Videos

Discharge Summary Forms01:31

Discharge Summary Forms

The discharge summary is crucial as it enables a smooth transition from a healthcare facility to a patient's home or another care setting. This critical document facilitates seamless continuity of care, ensuring patients receive the necessary support and attention.
Here's a detailed look at the key components and guidelines for preparing a discharge summary:
Documentation of Nursing Diagnosis01:10

Documentation of Nursing Diagnosis

The nurse documents nursing diagnoses and enters them into the patient record. The identified patient's nursing diagnosis is either written out with a plan of care or entered into the electronic health record.
In some settings, data-driven computerized decision support systems are in place, allowing for more accurate nursing diagnoses. The database within one of these systems includes diagnostic labels defining characteristics, activities, and indicators for nursing. A nurse enters assessment...
Formulating and Validating Nursing Diagnosis II01:25

Formulating and Validating Nursing Diagnosis II

Nursing diagnoses represent a problem validated by major defining characteristics. There are four categories of nursing diagnoses: problem-focused, risk, health promotion or wellness, and syndrome. The anatomy of a nursing diagnosis includes three components: problem statement or diagnostic label, defining characteristics, and related factors.
Risk nursing diagnoses represent clinical judgments of an individual, family, or community more vulnerable to developing the health problem than others...
Methods of Documentation I: Source-Oriented Records01:18

Methods of Documentation I: Source-Oriented Records

Source-oriented records, or SOR, are medical record-keeping organized by the data source. The SOR system was first developed in the mid-1900s to organize the growing patient data in hospitals and other healthcare facilities.
In an SOR, each discipline involved in patient care maintains a separate medical record section. This record-keeping method enables easy tracking of patient progress and ensures healthcare staff have access to up-to-date information.
Key Attributes include the following:
Planning Nursing Care I01:21

Planning Nursing Care I

The planning phase of the nursing process helps nurses set priorities, outline patient-centered goals and expected outcomes, and tailor nursing interventions to align with the aligned care plan. Through the planning phase, the nurse applies critical thinking skills to align and develop interventions according to the patient's needs. It provides continuity of care allowing patients to receive the maximum benefit from treatment. It serves as a pilot plan for allocating individual staff to a...
Flow Sheet01:17

Flow Sheet

Flowsheets are valuable tools in nursing documentation. They enable healthcare professionals to efficiently record and monitor various patient assessments and measurements in a consolidated format.
Here's a closer look at the examples of flowsheets commonly used by nurses:
Graphic Sheet Documentation: