Electronic discharge summary

BACKGROUND: The use of patient health and treatment information captured in structured and unstructured formats in computerized electronic health record (EHR) repositories could potentially augment the detection of safety signals for drug products regulated by the US Food and Drug Administration (FDA). Natural language processing and other artificial intelligence (AI) techniques provide novel methodologies that could be leveraged to extract clinically useful information from EHR resources...

BACKGROUND: The application of standardized patient summaries would reduce the risk of information overload and related problems for physicians and nurses. Although the International Patient Summary (IPS) standard has been developed, disseminating its applications has challenges, including data conversion of existing systems and development of application matching with common use cases in Japan. This study aimed to develop a patient summary application that summarizes and visualizes patient information accumulated by existing systems...

OBJECTIVES: Prior research suggests that errors occur frequently for patients with medical complexity during the hospital-to-home transition. Less is known about effective postdischarge communication strategies for this population. We aimed to assess rates of 30-day (1) postdischarge incidents and (2) readmissions and emergency department (ED) visits before and after implementing a hospital-to-home intervention. METHODS: We conducted a prospective intervention study of children with medical complexity discharged at a children's hospital from April 2018 to March 2020...

BACKGROUND: Abstracting cerebrovascular disease (CeVD) from inpatient electronic medical records (EMRs) through natural language processing (NLP) is pivotal for automated disease surveillance and improving patient outcomes. Existing methods rely on coders' abstraction, which has time delays and under-coding issues. This study sought to develop an NLP-based method to detect CeVD using EMR clinical notes. METHODS: CeVD status was confirmed through a chart review on randomly selected hospitalized patients who were 18 years or older and discharged from 3 hospitals in Calgary, Alberta, Canada, between January 1 and June 30, 2015...

OBJECTIVE: Generation of automated clinical notes has been posited as a strategy to mitigate physician burnout. In particular, an automated narrative summary of a patient's hospital stay could supplement the hospital course section of the discharge summary that inpatient physicians document in electronic health record (EHR) systems. In the current study, we developed and evaluated an automated method for summarizing the hospital course section using encoder-decoder sequence-to-sequence transformer models...

3, 3', 4, 4', 5-pentachlorobiphenyl (PCB126) is extensively utilized in electronic products, lubricant, and insecticide due to its excellent chemical stability and insulation prosperity, resulting in its frequent detection in environment. In addition, atmospheric deposition, as well as industrial and urban wastewater discharge can also lead to PCB126 contamination in marine environment, triggering damages to the tissues of aquatic organisms through oxidative stress. Astilbin is a type of flavonoid compound found in plants that plays a crucial role in providing powerful antioxidant and anti-inflammatory properties...

BACKGROUND: The aim of this study was to assess the quality of effective discharge communication to primary practice from a hospital that uses ieMR (integrated electronic Medical Record), a complete electronic prescribing/medical record platform. METHODS: A retrospective quantitative analysis of 232 discharge encounters from a major tertiary hospital assessed the discharge summary quality; timeliness, completeness and medication information. RESULTS: Median time to discharge summary was 1day...

ObjectiveThe objective of this study was to evaluate changes in the inclusion of pertinent information on electronic discharge summaries (eDS) after implementation of a revised template and electronic medical record (EMR) workflow.MethodsA retrospective medical record audit of eDS at three metropolitan hospitals was undertaken for adult inpatient encounters in June 2021 (pre-intervention, n = 100) and June 2022 (post-intervention, n = 100). The eDS were evaluated against 16 components listed in the Australian National Guidelines for the On-Screen Display of Discharge Summaries...

BACKGROUND: Although chat generative pre-trained transformer (ChatGPT) has made several successful attempts in the medical field, most notably in answering medical questions in English, no studies have evaluated ChatGPT's performance in a Chinese context for a medical task. OBJECTIVE: The aim of this study was to evaluate ChatGPT's ability to understand medical knowledge in Chinese, as well as its potential to serve as an electronic health infrastructure for medical development, by evaluating its performance in medical examinations, records, and education...

INTRODUCTION: Deep sternal wound infections (DSWI) are so serious and costly that hospital services continue to strive to control and prevent these outcomes. Microcosting is the more accurate approach in economic healthcare evaluation, but there are no studies in this field applying this method to compare DSWI after isolated coronary artery bypass grafting (CABG). This study aims to evaluate the incremental risk-adjusted costs of DSWI on isolated CABG. METHODS: This is a retrospective, single-center observational cohort study with a propensity score matching for infected and non-infected patients to compare incremental risk-adjusted costs between groups...

AIM: Recent advances in natural language processing models are expected to provide diagnostic assistance in psychiatry from history of present illness (HPI). However, existing studies have been limited, with the target diseases including only major diseases, small sample sizes, or no comparison with diagnoses made by psychiatrists to ensure accuracy. Therefore, we formulated an accurate diagnostic model that covers all psychiatric disorders. METHODS: HPIs and diagnoses were extracted from discharge summaries of 2642 cases at the Nara Medical University Hospital, Japan, from May 21, 2007, to May 31, 2021...

The performance of lead-acid batteries could be significantly increased by incorporating carbon materials into the negative electrodes. In this study, a modified carbon material developed via a simple high-temperature calcination method was employed as a negative electrode additive, and we have named it as follows: N-doped chitosan-derived carbon (NCC). The performance of this material was compared with a control battery containing activated carbon (AC). X-ray diffraction (XRD), scanning electron microscopy (SEM) and Raman spectroscopy were engaged in analyzing the crystal structure and morphology of the material...

We assessed the generalizability of machine learning methods using natural language processing (NLP) techniques to detect adverse drug events (ADEs) from clinical narratives in electronic medical records (EMRs). We constructed a new corpus correlating drugs with adverse drug events using 1,394 clinical notes of 47 randomly selected patients who received immune checkpoint inhibitors (ICIs) from 2011 to 2018 at The Ohio State University James Cancer Hospital, annotating 189 drug-ADE relations in single sentences within the medical records...

BACKGROUND AND OBJECTIVES: Despite use of standardized electronic health record templates, the structure of discharge summaries may hinder communication from inpatient settings to primary care providers (PCPs). We developed an enhanced electronic discharge summary template to improve PCP satisfaction with written discharge summaries targeting diagnoses, medication reconciliation, laboratory test results, specialist follow-up, and recommendations. METHODS: Resident template usage was measured using statistical process control charts...

BACKGROUND: Although stroke is well recognized as a critical disease, treatment options are often limited. Inpatient stroke encounters carry critical information regarding the mechanisms of stroke and patient outcomes; however, these data are typically formatted to support administrative functions instead of research. To support improvements in the care of patients with stroke, a substantive research data platform is needed. OBJECTIVE: To advance a stroke-oriented learning health care system, we sought to establish a comprehensive research repository of stroke data using the Houston Methodist electronic health record (EHR) system...

The aging global patient population with multimorbidity and concomitant polypharmacy is at increased risk for acute and chronic kidney disease, particularly with severe additional disease states or invasive surgical procedures. Because from the expertise of more than 58,600 self-reviewed medications, adverse drug reactions, drug interactions, inadequate dosing, and contraindications all proved to cause or exacerbate the worsening of renal function, we analyzed the association of an electronic patient record- and Summaries of Product Characteristics (SmPCs)-based comprehensive individual pharmacotherapy management (IPM) in the setting of 14 daily interdisciplinary patient visits with the outcome: further renal impairment with reduction of eGFR ≥ 20 mL/min (redGFR) in hospitalized trauma patients ≥ 70 years of age...

UNLABELLED: Neonatal intensive care unit (NICU) graduates require complex services after discharge. The NICU discharge process at Children's Hospital at Montefiore-Weiler, Bronx, NY (CHAM-Weiler) lacked a system for routine primary care provider (PCP) notification. Here, we describe a quality improvement project to improve communication with PCPs to ensure communication of critical information and plans. METHODS: We assembled a multidisciplinary team and collected baseline data on discharge communication frequency and quality...

Introduction Discharge summaries (DS), which are sent from inpatient to outpatient settings, transmit critical clinical information. DS play a crucial role in the discharge process since they provide critical information about the patients that is simple to remember and help with patient follow-up in the community. This audit sought to determine if a quality improvement (QI) program may have an influence on the severity of mistakes at the moment of discharge and to assess the existing degree of inconsistencies on handwritten DS for orthopaedic patients...

ObjectivesTo explore general practitioners' perspectives on the discharge summaries they receive about their patients who have been discharged from hospital.MethodsA survey of general practitioners in the catchment of a major metropolitan South Australian health service consisting of three teaching hospitals was undertaken. Surveys were disseminated electronically and via hardcopy mailout to general practitioners. The 36-question survey focused on five constructs of discharge summaries: accessibility, length and clarity, format, transparency, and medicines content...

Structurally optimized transition metal phosphides are identified as a promising avenue for the commercialization of lithium-sulfur (Li-S) batteries. In this study, a CoP nanoparticle-doped hollow ordered mesoporous carbon sphere (CoP-OMCS) is developed as a S host with a "Confinement-Adsorption-Catalysis" triple effect for Li-S batteries. The Li-S batteries with CoP-OMCS/S cathode demonstrate excellent performance, delivering a discharge capacity of 1148 mAh g-1 at 0.5 C and good cycling stability with a low long-cycle capacity decay rate of 0...