Analyzing Operative Note Structure in Development of a Section Header Resource

Operative notes contain essential details of surgical procedures and are an important form of clinical documentation. Sections within operative notes segment provide high level note structure. We evaluated the HL7 Implementation Guide for Clinical Document Architecture Release 2.0 Operative Note Draft Standard for Trial Use (HL7-ON DSTU) Release 1 as well as Logical Observation Identifiers Names and Codes (LOINC®) section names on 384 unique section headers from 362,311 operative notes. Overall, HL7-ON DSTU alone and HL7-ON DSTU with LOINC® section headers covered 66% and 79% of sections headers (93% and 98% of header instances), respectively. Section headers contained large numbers of synonyms, formatting variation, and variation of word forms, as well as smaller numbers of compound sections and issues with mismatches in header granularity. Robust operative note section mapping is important for clinical note interoperability and effective use of operative notes by natural language processing systems. The resulting operative note section resource is made publicly available.