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    AMIA Annu Symp Proc. 2008 Nov 6:753-7.

    Content and structure of clinical problem lists: a corpus analysis.

    Van Vleck TT, Wilcox A, Stetson PD, Johnson SB, Elhadad N.

    Department of Biomedical Informatics, Columbia University, New York, NY, USA.

    In the interest of designing an automated high-level, longitudinal clinical summary of a patient record, we analyze traditional ways in which medical problems pertaining to the patient are summarized in the electronic health record. The patient problem list has become a commonly used proxy for a summary of patient history and automated methods have been proposed to generate it. However, little research has been conducted on how to structure the problem list in a manner most effective for supporting clinical care. This study analyzes the structure and content of the Past Medical History (PMH) sections of a large corpus of clinical notes, as a proxy for problem lists. Findings show that when listing patients history, physicians convey several semantic types of information, not only problems. Furthermore, they often group related concepts in a single line of the PMH. In contrast, traditional problem lists allow only a simple enumeration of coded terms. Content analysis goes on to reiterate the value of more complex representations as well as provide valuable data and guidelines for automated generation of a clinical summary.

    PMID: 18999284 [PubMed - in process]

    PMCID: 2655994

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