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Fast, Structured Clinical Documentation via Contextual Autocomplete

2020/07/29 by Divya Gopinath, Gopinath, Divya, Monica Agrawal +10 · 16 citations
Biochemistry, Genetics and Molecular Biology · Computer Science · Mathematics · Psychology · #Biomedical Text Mining and Ontologies #Business #Computation and Language (cs.CL) #Computer science #Documentation #FOS: Computer and information sciences #Information Retrieval (cs.IR) #Machine Learning (cs.LG) #Machine Learning (stat.ML) #Natural Language Processing Techniques #Process management #Programming language #Psychology #Topic Modeling #cs.CL #cs.IR #cs.LG #stat.ML

paper · pdf · doi:10.48550/arxiv.2007.15153

published in arXiv (Cornell University) (Cornell University) · Published in Machine Learning for Healthcare 2020 conference

arxiv created 2020/07/29 · openalex publication_date 2020/07/29 · arxiv updated 2020/07/31 · openalex created_date 2025/10/10 · openalex updated_date 2026/07/28

Abstract

We present a system that uses a learned autocompletion mechanism to facilitate rapid creation of semi-structured clinical documentation. We dynamically suggest relevant clinical concepts as a doctor drafts a note by leveraging features from both unstructured and structured medical data. By constraining our architecture to shallow neural networks, we are able to make these suggestions in real time. Furthermore, as our algorithm is used to write a note, we can automatically annotate the documentation with clean labels of clinical concepts drawn from medical vocabularies, making notes more structured and readable for physicians, patients, and future algorithms. To our knowledge, this system is the only machine learning-based documentation utility for clinical notes deployed in a live hospital setting, and it reduces keystroke burden of clinical concepts by 67% in real environments.

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