从ADHD患者的电子健康记录中提取数据揭示儿科医生对教育支持和文件收集的讨论。

Q3 Medicine
Katherine Tennant Beenen, Nicole Garton, Emily Carroll, Ashley Tang, Shamsi Berry, Kevin H Lee, Theresa McGoff, Neelkamal Soares
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引用次数: 0

摘要

初级保健医生(pcp)在识别和管理注意缺陷多动障碍(ADHD)方面发挥着重要作用。与教育干预讨论相关的pcp实践研究缺乏。我们使用自然语言处理进行了回顾性图表回顾,以提取门诊诊所pcp的频率数据:1)与患者和护理人员讨论教育支持;2)取得教育记录。大约四分之三的患者至少有一个与教育支持相关的术语包含在至少一个笔记中,但只有13%的患者至少有一个教育记录上传到电子健康记录(EHR)中。将教育文档上传到电子病历与在注释中包含与教育支持相关的术语之间没有关联。这些记录中几乎有一半(48%)的标签不清楚。有必要对pcp进行进一步教育,以增加对教育支持和获得教育记录的讨论,并与卫生信息管理专业人员就标签进行合作。
本文章由计算机程序翻译,如有差异,请以英文原文为准。
Extracting Data from the Electronic Health Record of Patients with ADHD Reveals Pediatricians' Discussions of Educational Support and Document Collection.

Primary care physicians (PCPs) have an important role in the identification and management of Attention Deficit Hyperactivity Disorder (ADHD). There is a paucity of research on PCPs' practices related to the discussion of educational interventions. We conducted a retrospective chart review using Natural Language Processing to extract data on how often PCPs in an outpatient clinic: 1) discuss educational support with patients and caregivers; and 2) obtain educational records. About three-quarters of patients had at least one term related to educational support included in at least one note, but only 13 percent of patients had at least one educational record uploaded into the electronic health record (EHR). There was no association between having an educational document uploaded into the EHR and inclusion of a term related to educational support in a note. Almost half (48 percent) of these records were unclearly labeled. Further education of PCPs is warranted to increase discussions of educational support and obtaining educational records, as is collaboration with health information management professionals around labeling.

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来源期刊
CiteScore
1.90
自引率
0.00%
发文量
0
期刊介绍: Perspectives in Health Information Management is a scholarly, peer-reviewed research journal whose mission is to advance health information management practice and to encourage interdisciplinary collaboration between HIM professionals and others in disciplines supporting the advancement of the management of health information. The primary focus is to promote the linkage of practice, education, and research and to provide contributions to the understanding or improvement of health information management processes and outcomes.
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