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Information heterogeneity between progress notes by physicians and nurses for inpatients with digestive system
Yukinori Mashima1,2, Masatoshi Tanigawa3, Hideto Yokoi3,4
1Clinical Research Support Center, Kagawa University Hospital, 1750-1 Ikenobe, Miki-cho, Kita-gun, Kagawa, 761-0793, Japan. mashima-yukinori@umin.ac.jp.
Scientific Reports
|April 1, 2024
Summary
Nurses extract more symptoms (R codes) from patient progress notes than physicians. Physicians, however, more frequently document digestive system symptoms and disease names, reflecting their specialty. This highlights information heterogeneity in medical records.
Area of Science:
- Medical Informatics
- Clinical Documentation Analysis
- Natural Language Processing in Healthcare
Background:
- Physician and nurse progress notes contain vital patient information but exhibit heterogeneity.
- Understanding this heterogeneity is crucial for developing medical artificial intelligence (AI) applications.
- Previous studies have not comprehensively analyzed the differences in information content between physician and nurse notes.
Purpose of the Study:
- To investigate the differences in symptom and disease extraction from physician versus nurse progress notes.
- To quantify the heterogeneity in clinical documentation based on the authoring healthcare professional.
- To provide insights into the data characteristics for future medical AI development.
Main Methods:
- Analysis of 806 days of progress notes from 83 hospitalized patients in Gastroenterology.
- Utilized MedNER-J natural language processing software to extract International Classification of Diseases (ICD) Chapter 18 (R codes) for symptoms.
- Calculated R-code extraction rates and compared them between physician and nurse notes, including specific subcategories and disease chapters.
Main Results:
- Nurses had a significantly higher overall R-code extraction rate (75.2%) compared to physicians (68.5%).
- Physicians more frequently extracted digestive system symptoms (R10-R19: 44.2% vs. 37.5%) and disease names (ICD Chapter 11: 68.4% vs. 30.9%).
- These differences reflect the distinct documentation patterns and specialties of physicians and nurses.
Conclusions:
- Significant heterogeneity exists in the information captured in physician and nurse progress notes.
- Nurses capture a broader range of symptoms, while physicians focus more on specific diseases and their specialty.
- Recognizing this information heterogeneity is a foundational step for advancing medical AI and improving clinical data utilization.
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