Terminologia de Interface: processamento de linguagem natural de dados clínicos em narrativas do Prontuário Eletrônico do Paciente

• Autor(a) principal: Souza, Amanda Damasceno de
• Data de Publicação: 2024
• Outros Autores: Dutra, Frederico Giffoni de Carvalho, Corrêa, Fábio, Silva, Helton Júnio da, Ribeiro, Jurema Suely de Araújo Nery, Felipe, Eduardo Ribeiro
• Tipo de documento: Artigo
• Idioma: por
• Título da fonte: Encontros Bibli
• Texto Completo: https://periodicos.ufsc.br/index.php/eb/article/view/94983
• topic: Registros Eletrônicos de Saúde; Dados de Saúde Gerados pelo Paciente; Recuperação da informação; Ginecologia; Processamento de linguagem Natural

Objective: To present the retrieval and analysis of clinical data from anamneses in the. Electronic Health Record (EHR), referred to in this research as Interface Terminology. Methods:The clinical data collection process in this research was carried out on electronic patient records from a private hospital.  The data sample consisted of 18,256 anamneses from the field of gynecology in 2018. The clinical data was retrieved through Natural Language Processing using the Python language. The most frequent terms related to clinical data were analysed, such as abbreviations and acronyms, stop words, procedures, and n-grams. Results: Clinical data has the potential to be reused for scientific production, epidemiological profiling and the creation of dictionaries and enrichment of controlled vocabularies for EHR and other health information systems. They are also important in defining algorithms for information retrieval. As a result, a repository was created in OSF containing spreadsheets and tables with clinical data for reuse in algorithm delimitation, word cloud creation and to identify the most frequent terms in electronic patient records in the field of Gynecology, while the algorithms used in information retrieval were made available in GitHub. The data has been published in the OSF: https://osf.io/de43a/. Conclusions: Clinical data is information about the patient that is used for care purposes, hospital administrative issues, research related to the patient's health and illness. The Interface Terminology, exemplified in the research hospital's EHR, presented a diversity of clinical data in the anamneses.