Table 1.
Description How Each Concept Is Flagged Into (1) History, (2) Negation, (3) Uncertainty‚ and (4) Hypotheticals
| Flagged criteria | Types | Examples |
|---|---|---|
| History | PMH | “PMH: Myocardial infarction (MI), stroke, splenectomy at age 53…” “Patient has a history of post-operative nausea and vomiting (PONV) and difficult intubation…” |
| Family history | “Father died at age 73 of cerebrovascular accident (CVA)...” “Mother had liver disease from alcoholic (EtOH) cirrhosis…” |
|
| Negations | Pertinent negatives | “Patient denies hematuria, fevers, chills night sweats, chest pain, shortness of breath (SOB), nausea…” “Negative for: palpitations, syncope, chest pain, orthopnea…” “Patient has no weight loss, fevers, or chills…” |
| Rule-outs/exclusions | “Negative sputum culture renders an infectious etiology unlikely…” “Chest x-ray (CXR) rules out the possibility of pneumonia…” |
|
| Uncertainties | Differential diagnosis/abstractions | “CXR suggestive of lobar pneumonia of the right upper lobe (RUL)” “Patient presents with symptoms likely due to ____” “If symptoms persist, consider oral glucocorticoid therapy…” “Iron deficiency anemia unlikely given labs” |
| Recommendations and referrals | “Patient recommended to start AEDs for seizure prophylaxis” | |
| Qualifiers | “Patient’s lab indicate borderline anemia…” | |
| Hypotheticals | List of potential adverse outcomes following a procedure | “Patient was informed about the possible anesthetic complications including DVT, heart attack, stroke, and death.” |
| Risk factors | “Patient has uncontrolled HTN and diabetes, which are risk factors for stroke…” | |
| Patient education | “We discussed the risks of testosterone replacement therapy including polycythemia with stroke, MI, and recurrent PE…” |
Those that are considered family history, negation, or hypothetical were removed as pertinent results.
Highlighted cells correspond to the flags that were excluded from the model output for the study.
Abbreviations: AED, anti-epileptic drug; DVT, deep vein thrombosis; EtOH, alcohol; HTN, hypertension; PE, pulmonary embolism; PMH, past medical history; RUL, right upper lobe.