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ChatGPT's Ability to Assist with Clinical Documentation: A Randomized Controlled Trial
Hayden P Baker1, Emma Dwyer, Senthooran Kalidoss
1From the Department of Orthopaedic Surgery, University of Chicago, Chicago, IL.
ChatGPT shows potential for improving clinical documentation by generating more comprehensive histories of present illness (HPI). However, accuracy concerns require further investigation before widespread adoption in healthcare settings.
Area of Science:
- Medical Informatics
- Artificial Intelligence in Healthcare
- Clinical Documentation
Background:
- Effective clinical documentation is vital for healthcare communication and patient records.
- Artificial intelligence (AI) tools like chatbots offer potential assistance in clinical documentation.
- ChatGPT, a conversational AI, can generate human-like text responses.
Purpose of the Study:
- To investigate ChatGPT's capability in assisting with the creation of histories of present illness (HPI).
- To compare ChatGPT's performance against traditional documentation methods (typing and dictation).
Main Methods:
- A blinded, randomized controlled study involving 11 participants (medical students to attending surgeons).
- Participants documented HPIs from standardized patients using typing, dictation, or ChatGPT.
- Comparison of documentation techniques based on speed, quality (Physician Documentation Quality Instrument score), and accuracy.
Main Results:
- ChatGPT produced longer and higher quality HPIs than typing and dictation, but was slower than dictation.
- Dictation was the fastest method.
- ChatGPT introduced erroneous information in 36% of documents, with low reviewer agreement on quality.
Conclusions:
- ChatGPT has the potential to enhance clinical documentation, yielding more comprehensive HPIs.
- Further research is essential to address concerns regarding privacy, bias, and data accuracy.
- Current limitations necessitate caution before integrating ChatGPT into routine clinical practice.
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