@inproceedings{92411ab3c677448abcdcc23c13832d2b,
title = "Analyzing Operative Note Structure in Development of a Section Header Resource",
abstract = "Operative notes contain essential details of surgical procedures and are an important form of clinical documentation. Sections within operative notes segment provide high level note structure. We evaluated the HL7 Implementation Guide for Clinical Document Architecture Release 2.0 Operative Note Draft Standard for Trial Use (HL7-ON DSTU) Release 1 as well as Logical Observation Identifiers Names and Codes (LOINC{\textregistered}) section names on 384 unique section headers from 362,311 operative notes. Overall, HL7-ON DSTU alone and HL7-ON DSTU with LOINC{\textregistered} section headers covered 66% and 79% of sections headers (93% and 98% of header instances), respectively. Section headers contained large numbers of synonyms, formatting variation, and variation of word forms, as well as smaller numbers of compound sections and issues with mismatches in header granularity. Robust operative note section mapping is important for clinical note interoperability and effective use of operative notes by natural language processing systems. The resulting operative note section resource is made publicly available.",
keywords = "Controlled, Documentation, Electronic Health Records, Medical History Taking/methods, Operative, Quality and Safety, Surgical Procedures, Vocabulary",
author = "Melton, {Genevieve B.} and Yan Wang and Elliot Arsoniadis and Pakhomov, {Serguei V S} and Adam, {Terrence J.} and Kwaan, {Mary R.} and Rothenberger, {David A.} and Chen, {Elizabeth S.}",
year = "2015",
month = jan,
day = "1",
doi = "10.3233/978-1-61499-564-7-821",
language = "English (US)",
series = "Studies in Health Technology and Informatics",
publisher = "IOS Press",
pages = "821--826",
editor = "Andrew Georgiou and Sarkar, {Indra Neil} and {de Azevedo Marques}, {Paulo Mazzoncini}",
booktitle = "MEDINFO 2015",
note = "15th World Congress on Health and Biomedical Informatics, MEDINFO 2015 ; Conference date: 19-08-2015 Through 23-08-2015",
}