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arXiv 2109.11451cs.HC
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MedKnowts:电子健康档案的统一文档编制和信息检索

MedKnowts: Unified Documentation and Information Retrieval for Electronic Health Records

Luke Murray, Divya Gopinath, Monica Agrawal, Steven Horng, David Sontag, David R. Karger

摘要:

临床文档可以通过电子健康记录进行转换,但文档过程仍然是一个繁琐、耗时且容易出错的过程。临床医生面临着多方面的需求和支离破碎的信息探索和文档界面。这些挑战在急诊科更加严重--临床医生经常在一个班次中看到35名患者,在此期间,他们必须综合以前未知的患者的医疗记录,以便制定量身定制的诊断和治疗计划。为了更好地支持这种信息合成,临床文档工具必须能够快速访问患者的医疗记录。MedKnowts是一个集成的笔记编辑器和信息检索系统,它统一了文档和搜索过程,并提供了简明的综合概念为导向的病人的医疗记录片。MedKnowts自动捕获结构化数据,同时仍然允许用户使用自然语言的灵活性。MedKnowts利用这种结构来实现更轻松的长注释解析、自动填充文本和主动信息检索,从而减轻文档负担。

英文摘要:

Clinical documentation can be transformed by Electronic Health Records, yet the documentation process is still a tedious, time-consuming, and error-prone process. Clinicians are faced with multi-faceted requirements and fragmented interfaces for information exploration and documentation. These challenges are only exacerbated in the Emergency Department -- clinicians often see 35 patients in one shift, during which they have to synthesize an often previously unknown patient's medical records in order to reach a tailored diagnosis and treatment plan. To better support this information synthesis, clinical documentation tools must enable rapid contextual access to the patient's medical record. MedKnowts is an integrated note-taking editor and information retrieval system which unifies the documentation and search process and provides concise synthesized concept-oriented slices of the patient's medical record. MedKnowts automatically captures structured data while still allowing users the flexibility of natural language. MedKnowts leverages this structure to enable easier parsing of long notes, auto-populated text, and proactive information retrieval, easing the documentation burden.

机构、总结、中文摘要均由AI分析而来,可能存在错误,请以论文正文为准。

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