I'm not burned out. This is how I write notes.

IF 2.5 Q2 HEALTH CARE SCIENCES & SERVICES JAMIA Open Pub Date : 2023-11-28 eCollection Date: 2023-12-01 DOI:10.1093/jamiaopen/ooad099
Thomas H Payne, Grace K Turner
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Abstract

Objectives: We describe an automated transcription system that addresses many documentation problems and fits within scheduled clinical hours.

Materials and methods: During visits, the provider listens to the patient while maintaining eye contact and making brief notes on paper. Immediately after the visit conclusion and before the next, the provider makes a short voice recording on a smartphone which is transmitted to the system. The system uses a public domain general language model, and a hypertuned provider-specific language model that is iteratively refined as each produced note is edited by the physician, followed by final automated processing steps to add any templated text to the note.

Results: The provider leaves the clinic having completed all voice files, median duration 3.4 minutes. Created notes are formatted as preferred and are a median of 363 words (range 125-1175).

Discussion: This approach permits documentation to occur almost entirely within scheduled clinic hours, without copy-forward errors, and without interference with patient-provider interaction.

Conclusion: Though no documentation method is likely to appeal to all, this approach may appeal to many physicians and avoid many current problems with documentation.

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我没有精疲力尽。这就是我写笔记的方式。
目的:我们描述了一个自动转录系统,解决了许多文件问题,并符合预定的临床时间。材料和方法:在就诊期间,提供者倾听患者,同时保持目光接触,并在纸上做简短的笔记。在访问结束后和下一次访问之前,提供者会在智能手机上录制一段简短的语音录音,并将其传输到系统中。该系统使用公共领域通用语言模型和超调的提供者特定语言模型,该模型在医生编辑每个生成的笔记时进行迭代改进,然后进行最终的自动化处理步骤,将任何模板文本添加到笔记中。结果:提供者完成所有语音文件离开诊所,中位持续时间3.4分钟。创建的注释按偏好格式化,中位数为363个单词(范围为125-1175)。讨论:这种方法允许记录几乎完全在预定的诊所时间内进行,没有复制转发错误,也不会干扰患者与提供者的互动。结论:虽然没有一种记录方法可能对所有人都有吸引力,但这种方法可能对许多医生有吸引力,并避免了目前记录的许多问题。
本文章由计算机程序翻译,如有差异,请以英文原文为准。
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来源期刊
JAMIA Open
JAMIA Open Medicine-Health Informatics
CiteScore
4.10
自引率
4.80%
发文量
102
审稿时长
16 weeks
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