Intelligent Data Assistance for Patient Note Creation

We present intelligent data assistance for the creation of daily patient progress notes by hospital physicians. We report on the development of prototype note creation software and findings from experimental use of the prototype by physicians in two intensive care units. The physicians were quite positive about the need for, and value of, intelligent data assistance for note creation and provided suggestions for additional features. Analysis of the feedback revealed strong agreement among physicians in their preferences and suggestions, and supported the applicability of intelligent data assistance to medical note creation applications in general. We distill the findings to two categories of intelligent data assistance needed to create usable and useful medical note creation systems: (1) input assistance within the clinical document editor and (2) review assistance for system-provided patient information. We also discuss the need for lightweight user customization of data assistance to motivate future work.

By: Lauren Wilcox, Jie Lu, Jennifer Lai, Steven Feiner, Desmond Jordan

Published in: RC24705 in 2008


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