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Comprehensive clinical documentation is crucial for effective healthcare delivery, yet it poses a significant burden on healthcare professionals, leading to burnout, increased medical errors, and compromised patient safety. This paper…

人工智能 · 计算机科学 2024-05-29 Anjanava Biswas , Wrick Talukdar

Medical practitioners are rapidly adopting generative AI solutions for clinical documentation, leading to significant time savings and reduced stress. However, evaluating the quality of AI-generated documentation is a complex and ongoing…

计算与语言 · 计算机科学 2024-09-26 Jon Oleson

Writing clinical notes and documenting medical exams is a critical task for healthcare professionals, serving as a vital component of patient care documentation. However, manually writing these notes is time-consuming and can impact the…

计算与语言 · 计算机科学 2025-06-17 Yizhan Li , Sifan Wu , Christopher Smith , Thomas Lo , Bang Liu

The increasing administrative burden of medical documentation, particularly through Electronic Health Records (EHR), significantly reduces the time available for direct patient care and contributes to physician burnout. To address this…

音频与语音处理 · 电气工程与系统科学 2025-09-25 Hui Yi Leong , Yi Fan Gao , Shuai Ji , Bora Kalaycioglu , Uktu Pamuksuz

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…

机器学习 · 计算机科学 2020-07-31 Divya Gopinath , Monica Agrawal , Luke Murray , Steven Horng , David Karger , David Sontag

Large language models (LLMs), including zero-shot and few-shot paradigms, have shown promising capabilities in clinical text generation. However, real-world applications face two key challenges: (1) patient data is highly unstructured,…

计算与语言 · 计算机科学 2025-07-10 Garapati Keerthana , Manik Gupta

A growing body of work uses Natural Language Processing (NLP) methods to automatically generate medical notes from audio recordings of doctor-patient consultations. However, there are very few studies on how such systems could be used in…

Iterative RAG for multi-hop question answering faces challenges with lengthy contexts and the buildup of irrelevant information. This hinders a model's capacity to process and reason over retrieved content and limits performance. While…

Effective clinical history taking is a foundational yet underexplored component of clinical reasoning. While large language models (LLMs) have shown promise on static benchmarks, they often fall short in dynamic, multi-turn diagnostic…

计算与语言 · 计算机科学 2026-01-30 Yang Zhou , Zhenting Sheng , Mingrui Tan , Yuting Song , Jun Zhou , Yu Heng Kwan , Lian Leng Low , Yang Bai , Yong Liu

In recent years, the trend of deploying digital systems in numerous industries has hiked. The health sector has observed an extensive adoption of digital systems and services that generate significant medical records. Electronic health…

计算与语言 · 计算机科学 2022-03-01 Neel Kanwal , Giuseppe Rizzo

Following each patient visit, physicians draft long semi-structured clinical summaries called SOAP notes. While invaluable to clinicians and researchers, creating digital SOAP notes is burdensome, contributing to physician burnout. In this…

计算与语言 · 计算机科学 2021-06-03 Kundan Krishna , Sopan Khosla , Jeffrey P. Bigham , Zachary C. Lipton

With advances in generative artificial intelligence (AI), it is now possible to produce realistic-looking automated reports for preliminary reads of radiology images. This can expedite clinical workflows, improve accuracy and reduce overall…

人工智能 · 计算机科学 2025-06-03 Razi Mahmood , Diego Machado Reyes , Ge Wang , Mannudeep Kalra , Pingkun Yan

AI-powered medical scribes have emerged as a promising solution to alleviate the documentation burden in healthcare. Ambient AI scribes provide real-time transcription and automated data entry into Electronic Health Records (EHRs), with the…

人工智能 · 计算机科学 2024-10-22 Chanseo Lee , Sonu Kumar , Kimon A. Vogt , Sam Meraj

AI-generated clinical notes are increasingly used in healthcare, but evaluating their quality remains a challenge due to high subjectivity and limited scalability of expert review. Existing automated metrics often fail to align with…

计算与语言 · 计算机科学 2025-10-10 Karen Zhou , John Giorgi , Pranav Mani , Peng Xu , Davis Liang , Chenhao Tan

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…

计算与语言 · 计算机科学 2018-08-09 Peter J. Liu

Recent advances in artificial intelligence (AI) have made timely, scalable, and effective fact-checking increasingly feasible. One such deployment is X's Community Notes, which provides the AI Note Writer API to enable end-to-end automated…

计算机与社会 · 计算机科学 2026-05-19 Yilin Gong , Siqi Wu

Electronic health records (EHRs) are long, noisy, and often redundant, posing a major challenge for the clinicians who must navigate them. Large language models (LLMs) offer a promising solution for extracting and reasoning over this…

The discharge summary is a one of critical documents in the patient journey, encompassing all events experienced during hospitalization, including multiple visits, medications, tests, surgery/procedures, and admissions/discharge. Providing…

计算机视觉与模式识别 · 计算机科学 2024-02-20 Imjin Ahn , Hansle Gwon , Young-Hak Kim , Tae Joon Jun , Sanghyun Park

Clinical note generation aims to produce free-text summaries of a patient's condition and diagnostic process, with discharge instructions being a representative long-form example. While recent LLM-based methods pre-trained on general…

计算与语言 · 计算机科学 2025-08-12 Lo Pang-Yun Ting , Chengshuai Zhao , Yu-Hua Zeng , Yuan Jee Lim , Kun-Ta Chuang , Huan Liu

Clinician notes are a rich source of patient information but often contain inconsistencies due to varied writing styles, colloquialisms, abbreviations, medical jargon, grammatical errors, and non-standard formatting. These inconsistencies…

计算与语言 · 计算机科学 2025-01-03 Daniel B. Hier , Michael D. Carrithers , Thanh Son Do , Tayo Obafemi-Ajayi
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