Using Clinical Notes to Improve Health Care

Keywords

Essential health; Health services; Policy dialogue; Health inequalities

Introduction

When you visit your doctor’s workplace, a practician checks your very important signs and asks questions on however you’re feeling and why you’re there. The practician enters your responses into your electronic case history (EMR). Quantitative measures - your force per unit area, temperature and alternative very important signs - square measure entered as numbers into distinct fields within the EMR. Natural language process (NLP) is that the tool that adds utility to the current data. NLP opens doors to operationalize the info in ways in which build blessings across multiple sectors. We are able to use NLP to seek out insights that impact health care delivery and price - all whereas rising health outcomes for larger population teams [1].

Converting Clinical Notes into Powerful Information

Today’s health care suppliers square measure adept at managing conditions that square measure simply measured exploitation body chemistry, like blood or excretory product tests. These tests yield distinct numerical metrics that may be half-tracked over time, like sterol levels or a diabetic’s A1c levels. However, the signs and symptoms of advanced chronic health conditions don't seem to be continuously measurable by body chemistry, and suppliers square measure trying to find new ways in which to leverage alternative offered data [2].

The symptoms of chronic hindering pulmonic malady (COPD), as an example, embrace shortness of breath with physical activity, fatigue, cough, and chest pressure. The signs and markers of disorders like COPD and Alzheimer’s malady square measure, however, captured in clinical notes. Now, with the flexibility to unlock data exploitation NLP and machine learning, health suppliers will take and use the data in clinical notes on a far larger scale.

Improve Patient Health

The most popular form of home health care is nursing care, which varies based on the individual's needs. A licenced nurse may develop a treatment plan in consultation with the specialist. Wound treatment, ostomy treatment, intravenous therapy, drug management, patient supervision, pain control, and other health assistance are also examples of nursing care [3].

Physical, Occupational, and/or Speech Therapy

Following an illness or accident, certain patients may need assistance in relearning how to perform everyday activities or enhancing their voice. A physical therapy should formulate a recovery schedule to help a patient regain or improve muscle and joint function. A speech therapist may help a patient who has lost their ability to speak effectively recover it [2].

Medical Social Services

Hospital social workers provide patients with a range of programmes, including therapy and finding neighbourhood supports to aid in their rehabilitation. When the patient's medical situation is complicated and involves integration of various resources, certain social workers often act as the patient's case manager.

Care from Home Health Aides

The patient's simple personal needs, such as getting out of bed, sitting, washing, and dressing, will be helped by home health aides. Under the supervision of a nurse, some aides have undergone advanced training to help with more specialised treatment.

Homemaker or Basic Assistance Care

When a patient is seeking medical treatment at home, a homemaker or someone who assists with chores or duties will keep the house in order by cooking meals, doing laundry, grocery shopping, and other housekeeping tasks.

Companionship

Any patients who are alone at home can need company and supervision. Any companions can also help with housework.

Volunteer Care

Companionship, health care, lodging, social support, and/or paperwork aid are also examples of how volunteers from neighbourhood groups may offer basic relief to the patient.

Nutritional Support

Dieticians may come to a patient's home and perform nutritional tests and offer advice to help them adhere to their recovery plan.

Laboratory and X-ray Imaging

Certain medical examinations, such as blood and urine tests, should be done in the patient's own home. Furthermore, lab technicians may perform this service at home using portable X-ray devices.

Pharmaceutical Services

Health supplies and appliances can be shipped to your house. If the patient wants it, instruction in how to take drugs and use devices, including intravenous therapy, will be given.

Transportation

There are organisations that provide rides to and from hospital centres for care or physical tests.

Home-delivered Meals

Many societies provide this programme, known as Meals-on-Wheels, to patients at home who are unable to cook for themselves. Hot meals can be delivered several days a week, depending on the individual's preferences.

References

1. https://www.optum.com/business/resources/ai-in-healthcare/notes-improve-care.html#:~:text=Clinical%20notes%20allow%20payers%20and,and%20calculate%20health%20care%20utilization.
2. Mathioudakis A, et al. How to keep good clinical records. Breathe (Sheffield, England). 2016;12(4):369–373.
3. Rosenbloom ST, et al. Generating Clinical Notes for Electronic Health Record Systems. Appl Clin Inform. (2010);2010; 1(3):232–243.
4. Kim M. Using Clinical Documentation Improvement to Improve Patient Care. (2019); Retrieved from https://www.longwoods.com/content/25772/using-clinical-documentation-improvement-to-improve-patient-care