AUTOMATED CLINICAL INDICATOR RECOGNITION WITH NATURAL LANGUAGE PROCESSING

摘要

Computer-based, natural language processing systems and methods are provided for review of clinical documentation and other medical records, and for clinical documentation improvement. The systems and methods are configured to review documents in the record using a natural language processor and to identify clinical indicators with associated contextual information. The clinical indicators are compared to scenarios to generate markers based on an information model. The markers used to generate physician queries and other informational requests with supporting evidence for each query based on indicators identified in the record. In additional examples, pragmatic guidelines including business-based rules can also be utilized, either in combination with, or as part of, the scenarios in the information model.

主权项

1. A computer-based, natural language processing system comprising:
a computer processor operatively coupled to an interactive display; a database in communication with the computer processor, the database comprising memory for storing a medical record, the medical record comprising electronic documents relating to patient care; and a natural language processor module executing on the computer processor, the natural language processor module configured to:
review the electronic documents in the medical record;identify clinical indicators and associated contextual information in the electronic documents;compare the clinical indicators and associated contextual information to rule-based scenarios in an information model;generate a marker based the clinical indicators and associated contextual information, the marker identifying a record element associated with a medical condition relating to the patient care, wherein the record element is absent from the medical record; andgenerate a query describing the marker, in combination with evidence describing at least one of the clinical indicators and associated contextual information from which the marker was generated.