Analyzing Operative Note Structure in Development of a Section Header Resource

Genevieve B. Melton; Yan Wang; Elliot Arsoniadis; Serguei V S Pakhomov; Terrence J. Adam; Mary R. Kwaan; David A. Rothenberger; Elizabeth S. Chen

doi:10.3233/978-1-61499-564-7-821

Analyzing Operative Note Structure in Development of a Section Header Resource

Genevieve B. Melton, Yan Wang, Elliot Arsoniadis, Serguei V S Pakhomov, Terrence J. Adam, Mary R. Kwaan, David A. Rothenberger, Elizabeth S. Chen

Research output: Chapter in Book/Report/Conference proceeding › Conference contribution

4 Scopus citations

Abstract

Operative notes contain essential details of surgical procedures and are an important form of clinical documentation. Sections within operative notes segment provide high level note structure. We evaluated the HL7 Implementation Guide for Clinical Document Architecture Release 2.0 Operative Note Draft Standard for Trial Use (HL7-ON DSTU) Release 1 as well as Logical Observation Identifiers Names and Codes (LOINC®) section names on 384 unique section headers from 362,311 operative notes. Overall, HL7-ON DSTU alone and HL7-ON DSTU with LOINC® section headers covered 66% and 79% of sections headers (93% and 98% of header instances), respectively. Section headers contained large numbers of synonyms, formatting variation, and variation of word forms, as well as smaller numbers of compound sections and issues with mismatches in header granularity. Robust operative note section mapping is important for clinical note interoperability and effective use of operative notes by natural language processing systems. The resulting operative note section resource is made publicly available.

Original language	English (US)
Title of host publication	MEDINFO 2015
Subtitle of host publication	eHealth-Enabled Health - Proceedings of the 15th World Congress on Health and Biomedical Informatics
Editors	Andrew Georgiou, Indra Neil Sarkar, Paulo Mazzoncini de Azevedo Marques
Publisher	IOS Press
Pages	821-826
Number of pages	6
ISBN (Electronic)	9781614995630
DOIs	https://doi.org/10.3233/978-1-61499-564-7-821
State	Published - 2015
Event	15th World Congress on Health and Biomedical Informatics, MEDINFO 2015 - Sao Paulo, Brazil Duration: Aug 19 2015 → Aug 23 2015

Publication series

Name	Studies in Health Technology and Informatics
Volume	216
ISSN (Print)	0926-9630
ISSN (Electronic)	1879-8365

Other

Other	15th World Congress on Health and Biomedical Informatics, MEDINFO 2015
Country/Territory	Brazil
City	Sao Paulo
Period	8/19/15 → 8/23/15

Bibliographical note

Publisher Copyright:
© 2015 IMIA and IOS Press.

Keywords

Controlled
Documentation
Electronic Health Records
Medical History Taking/methods
Operative
Quality and Safety
Surgical Procedures
Vocabulary

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10.3233/978-1-61499-564-7-821

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Melton, G. B., Wang, Y., Arsoniadis, E., Pakhomov, S. V. S., Adam, T. J., Kwaan, M. R., Rothenberger, D. A., & Chen, E. S. (2015). Analyzing Operative Note Structure in Development of a Section Header Resource. In A. Georgiou, I. N. Sarkar, & P. M. de Azevedo Marques (Eds.), MEDINFO 2015: eHealth-Enabled Health - Proceedings of the 15th World Congress on Health and Biomedical Informatics (pp. 821-826). (Studies in Health Technology and Informatics; Vol. 216). IOS Press. https://doi.org/10.3233/978-1-61499-564-7-821

Analyzing Operative Note Structure in Development of a Section Header Resource. / Melton, Genevieve B.; Wang, Yan; Arsoniadis, Elliot et al.
MEDINFO 2015: eHealth-Enabled Health - Proceedings of the 15th World Congress on Health and Biomedical Informatics. ed. / Andrew Georgiou; Indra Neil Sarkar; Paulo Mazzoncini de Azevedo Marques. IOS Press, 2015. p. 821-826 (Studies in Health Technology and Informatics; Vol. 216).

Research output: Chapter in Book/Report/Conference proceeding › Conference contribution

Melton, GB, Wang, Y, Arsoniadis, E , Pakhomov, SVS , Adam, TJ, Kwaan, MR, Rothenberger, DA & Chen, ES 2015, Analyzing Operative Note Structure in Development of a Section Header Resource. in A Georgiou, IN Sarkar & PM de Azevedo Marques (eds), MEDINFO 2015: eHealth-Enabled Health - Proceedings of the 15th World Congress on Health and Biomedical Informatics. Studies in Health Technology and Informatics, vol. 216, IOS Press, pp. 821-826, 15th World Congress on Health and Biomedical Informatics, MEDINFO 2015, Sao Paulo, Brazil, 8/19/15. https://doi.org/10.3233/978-1-61499-564-7-821

Melton GB, Wang Y, Arsoniadis E , Pakhomov SVS , Adam TJ, Kwaan MR et al. Analyzing Operative Note Structure in Development of a Section Header Resource. In Georgiou A, Sarkar IN, de Azevedo Marques PM, editors, MEDINFO 2015: eHealth-Enabled Health - Proceedings of the 15th World Congress on Health and Biomedical Informatics. IOS Press. 2015. p. 821-826. (Studies in Health Technology and Informatics). doi: 10.3233/978-1-61499-564-7-821

Melton, Genevieve B. ; Wang, Yan ; Arsoniadis, Elliot et al. / Analyzing Operative Note Structure in Development of a Section Header Resource. MEDINFO 2015: eHealth-Enabled Health - Proceedings of the 15th World Congress on Health and Biomedical Informatics. editor / Andrew Georgiou ; Indra Neil Sarkar ; Paulo Mazzoncini de Azevedo Marques. IOS Press, 2015. pp. 821-826 (Studies in Health Technology and Informatics).

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Analyzing Operative Note Structure in Development of a Section Header Resource

Abstract

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