論文

2020年

Toward Design of an Agent-based Writing Support System for the SOAP Note: A Content Analysis of the Video-based Survey

ADVANCED BIOMEDICAL ENGINEERING
  • Lukman Heryawan
  • ,
  • Purnomo Husnul Khotimah
  • ,
  • Osamu Sugiyama
  • ,
  • Goshiro Yamamoto
  • ,
  • Luciano Henrique de Oliveira Santos
  • ,
  • Angga Eko Pramono
  • ,
  • Kazuya Okamoto
  • ,
  • Tomohiro Kuroda

9
開始ページ
146
終了ページ
153
記述言語
英語
掲載種別
研究論文(学術雑誌)
DOI
10.14326/abe.9.146
出版者・発行元
JAPANESE SOC MEDICAL & BIOLOGICAL ENGINEERING

Subjective, objective, assessment, and plan (SOAP) notes are widely used by physicians to document clinical reasoning in assessing, diagnosing, and treating patients. SOAP notes are also used in medical coding tasks for reimbursement of insurance claims. In Indonesia, medical coders who are independent from physicians assess SOAP notes to assign diagnostic codes and medical procedure codes based on the corresponding International Classification of Diseases standards. Discrepancies between physicians who write the SOAP notes and coders who assign diagnoses and treatments, may occur. These discrepancies were assessed by performing a video-based survey to understand the coder's perspective, allowing the development of a writing support system to achieve unproblematic SOAP notes. This survey found that problematic SOAP notes were not caused by a single problem but by multiple problems. Abbreviations used by physicians are the major problem in assigning diagnostic codes, whereas incomplete data are the major problem in determining planning. This survey also showed that problematic SOAP notes may contain helpful keywords for coders that can help in determining diagnosis and treatment. The findings show that the system should be able to recognize separate sections of the SOAP note to provide writing support features and identify helpful keywords to encourage physicians to write unproblematic SOAP notes.

リンク情報
DOI
https://doi.org/10.14326/abe.9.146
Web of Science
https://gateway.webofknowledge.com/gateway/Gateway.cgi?GWVersion=2&SrcAuth=JSTA_CEL&SrcApp=J_Gate_JST&DestLinkType=FullRecord&KeyUT=WOS:000609262700017&DestApp=WOS_CPL
ID情報
  • DOI : 10.14326/abe.9.146
  • ISSN : 2187-5219
  • Web of Science ID : WOS:000609262700017

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