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使用机器学习方法进行自然语言处理,以分析来自电子健康记录的非结构化患者报告结果:系统性审查

Jin-Ah Sim¹, Xiaolei Huang², Madeline R Horan³

¹Department of Epidemiology and Cancer Control, St. Jude Children's Research Hospital, Memphis, TN, United States; School of AI Convergence, Hallym University, Chuncheon, Republic of Korea.

Artificial intelligence in medicine

|December 2, 2023

概括

自然语言处理 (NLP) 和机器学习 (ML) 可以在电子健康记录 (EHR) 中分析患者报告的结果 (PRO). 虽然基于规则的NLP是常见的,但对于未来的临床应用,需要新的神经ML方法.

科学领域:

计算语言学计算语言学
医疗信息学医疗信息学
机器学习在医疗保健中的应用

关键词:

电子健康记录是电子健康记录.机器学习机器学习自然语言处理自然语言处理.患者报告的结果非结构化的临床叙述.

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Methods of Documentation VII: EMR

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Electronic Medical Records (EMRs) primarily center around electronically documenting patients' health information within a single healthcare organization or practice. They contain essential clinical data related to a patient's medical history, diagnoses, medications, treatment plans, lab results, and other pertinent information relevant to the specific encounter or episode of care. EMRs are designed to streamline documentation and workflow processes within individual healthcare...

Purpose of Health Records I

Purpose of Health Records I

The vital purpose of health records is to provide a complete and accurate account of a patient's medical history, including communication, diagnostic and therapeutic orders, care planning, research, and quality review.
Here's a breakdown of how health records serve these purposes:

Nursing Evaluation

Nursing Evaluation

The evaluation stage signals the end of the nursing process. The nurse gathers evaluative data to assess whether or not the patient has attained the expected results. Whereas the nurse collects data in the nursing assessment to identify the patient's health concerns, the evaluation stage data determines if the indicated health issues are resolved. Evaluative data collection includes two sections: the data acquired to evaluate patient outcomes and the time criteria for data collection.

Role of Communication in the Nursing Process III: Evaluation and Documentation

Role of Communication in the Nursing Process III: Evaluation and Documentation

A successful patient outcome depends mainly on the evaluation stage of the nursing process. Evaluation determines effectiveness by reviewing what was done previously after the completion of nursing interventions. Every time a healthcare professional steps in or administers treatment, they must reassess or evaluate the action to ensure the intended result. During the evaluation phase, there are three probable patient outcomes:

Documentation of Nursing Diagnosis

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...

Guidelines for Writing Outcome

Guidelines for Writing Outcome

When developing expected outcomes for a patient care plan, the nurse should adhere to the following recommendations:
Patient outcomes reflect the patient's response to the goal rather than what the nurse aims to achieve. Terminology should be observable and measurable to avoid the reader's interpretation. The desired outcome should be realistic and achievable in the designated care timeframe. Expected outcomes should align with adjunctive therapies. The outcome should enhance care...