Analyzing Operative Note Structure in Development of a Section Header Resource

Genevieve B. Melton, Yan Wang, Elliot Arsoniadis, Serguei V S Pakhomov, Terrence J. Adam, Mary R. Kwaan, David A. Rothenberger, Elizabeth S. Chen

Research output: Chapter in Book/Report/Conference proceedingConference contribution

4 Scopus citations


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®) section names on 384 unique section headers from 362,311 operative notes. Overall, HL7-ON DSTU alone and HL7-ON DSTU with LOINC® 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.

Original languageEnglish (US)
Title of host publicationMEDINFO 2015
Subtitle of host publicationeHealth-Enabled Health - Proceedings of the 15th World Congress on Health and Biomedical Informatics
EditorsAndrew Georgiou, Indra Neil Sarkar, Paulo Mazzoncini de Azevedo Marques
PublisherIOS Press
Number of pages6
ISBN (Electronic)9781614995630
StatePublished - 2015
Event15th World Congress on Health and Biomedical Informatics, MEDINFO 2015 - Sao Paulo, Brazil
Duration: Aug 19 2015Aug 23 2015

Publication series

NameStudies in Health Technology and Informatics
ISSN (Print)0926-9630
ISSN (Electronic)1879-8365


Other15th World Congress on Health and Biomedical Informatics, MEDINFO 2015
CitySao Paulo

Bibliographical note

Publisher Copyright:
© 2015 IMIA and IOS Press.


  • Controlled
  • Documentation
  • Electronic Health Records
  • Medical History Taking/methods
  • Operative
  • Quality and Safety
  • Surgical Procedures
  • Vocabulary


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