Clinicians spend a significant amount of time inputting free-form textual notes into Electronic Health Records (EHR) systems. Much of this documentation work is seen as a burden, reducing time spent with patients and contributing to clinician burnout. With the aspiration of AI-assisted note-writing, we propose a new language modeling task predicting the content of notes conditioned on past data from a patient's medical record, including patient demographics, labs, medications, and past notes. We train generative models using the public, de-identified MIMIC-III dataset and compare generated notes with those in the dataset on multiple measures. We find that much of the content can be predicted, and that many common templates found in notes can be learned. We discuss how such models can be useful in supporting assistive note-writing features such as error-detection and auto-complete.

本文提出了一种预测病历记录中病人的过去数据，包括人口统计学，检验，药物和过去的笔记，预测未来笔记内容的新型语言建模任务，并使用公开的、去个人化的MIMIC-III数据集训练生成模型。我们发现大部分笔记的内容都可以被预测，并且学习了许多常见的笔记模板。本文探讨了这样的模型如何在支持辅助笔记编写功能方面是有用的，比如错误检测和自动完成。

电子健康档案中的笔记撰写学习