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Identifying the Basis for Clinical Decisions - A Feasibility Study.

Petter Hurlen¹, Eirik Ofstad¹, Pål Gulbrandsen¹

¹Akershus University Hospital, Norway.

Studies in Health Technology and Informatics

|September 1, 2016

Summary

This study explored defining terms to identify the basis of clinical decisions from encounter transcriptions. Further research is needed to refine this approach for clinical decision support.

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Area of Science:

Medical Informatics
Clinical Decision Support

Background:

Clinical decisions are complex and often undocumented.
Identifying the basis of these decisions is crucial for improving healthcare quality and training.

Purpose of the Study:

To explore the feasibility of creating a standardized terminology for clinical decision-making.
To identify key terms that describe the rationale behind clinical choices in patient encounters.

Main Methods:

Analysis of transcribed clinical encounters with pre-identified decisions.
Exploratory study to define and categorize decision-related terms.

Main Results:

Initial set of terms identified for describing clinical decision basis.
Considerations for a structured vocabulary emerged from the analysis.

Conclusions:

Defining a specific terminology for clinical decisions is a complex but potentially valuable endeavor.
Further research is required to validate and expand the proposed terms for practical application.