Information heterogeneity between progress notes by physicians and nurses for inpatients with digestive system diseases

Abstract

AbstractThis study focused on the heterogeneity in progress notes written by physicians or nurses. A total of 806 days of progress notes written by physicians or nurses from 83 randomly selected patients hospitalized in the Gastroenterology Department at Kagawa University Hospital from January to December 2021 were analyzed. We extracted symptoms as the International Classification of Diseases (ICD) Chapter 18 (R00–R99, hereinafter R codes) from each progress note using MedNER-J natural language processing software and counted the days one or more symptoms were extracted to calculate the extraction rate. The R-code extraction rate was significantly higher from progress notes by nurses than by physicians (physicians 68.5% vs. nurses 75.2%; p = 0.00112), regardless of specialty. By contrast, the R-code subcategory R10–R19 for digestive system symptoms (44.2 vs. 37.5%, respectively; p = 0.00299) and many chapters of ICD codes for disease names, as represented by Chapter 11 K00–K93 (68.4 vs. 30.9%, respectively; p < 0.001), were frequently extracted from the progress notes by physicians, reflecting their specialty. We believe that understanding the information heterogeneity of medical documents, which can be the basis of medical artificial intelligence, is crucial, and this study is a pioneering step in that direction.