Academic Journal
Diagnosis decoded: a taxonomy and natural language processing analysis of the diagnosis section in German hospital discharge summaries.
| Τίτλος: | Diagnosis decoded: a taxonomy and natural language processing analysis of the diagnosis section in German hospital discharge summaries. |
|---|---|
| Συγγραφείς: | Frings J; Faculty of Health, School of Medicine, Witten/Herdecke University, Alfred-Herrhausen- Strasse 50, Witten, 58455, Germany.; Health Care Informatics, Faculty of Health, School of Medicine, Witten/Herdecke University, Pferdebachstrasse 11, Witten, 58455, Germany., Rust P; Faculty of Health, School of Medicine, Witten/Herdecke University, Alfred-Herrhausen- Strasse 50, Witten, 58455, Germany.; Health Care Informatics, Faculty of Health, School of Medicine, Witten/Herdecke University, Pferdebachstrasse 11, Witten, 58455, Germany., Jede F; MVZ Dr. Renard & Kollegen, Limbacher Straße 77, Schwabach, 91126, Germany., Meister S; Health Care Informatics, Faculty of Health, School of Medicine, Witten/Herdecke University, Pferdebachstrasse 11, Witten, 58455, Germany.; Department Healthcare, Fraunhofer Institute for Software and Systems Engineering ISST, Speicherstrasse 6, Dortmund, 44147, Germany., Prinz C; Department of Gastroenterology, Helios University Hospital Wuppertal, Witten/Herdecke University, Heusnerstrasse 40, Wuppertal, 42283, Germany., Fehring L; Faculty of Health, School of Medicine, Witten/Herdecke University, Alfred-Herrhausen- Strasse 50, Witten, 58455, Germany. Leonard.Fehring@uni-wh.de.; Health Care Informatics, Faculty of Health, School of Medicine, Witten/Herdecke University, Pferdebachstrasse 11, Witten, 58455, Germany. Leonard.Fehring@uni-wh.de.; Department of Gastroenterology, Helios University Hospital Wuppertal, Witten/Herdecke University, Heusnerstrasse 40, Wuppertal, 42283, Germany. Leonard.Fehring@uni-wh.de. |
| Πηγή: | Health care management science [Health Care Manag Sci] 2025 Dec; Vol. 28 (4), pp. 806-823. Date of Electronic Publication: 2025 Oct 29. |
| Τύπος έκδοσης: | Journal Article |
| Γλώσσα: | English |
| Στοιχεία περιοδικού: | Publisher: Baltzer Science Publishers Country of Publication: Netherlands NLM ID: 9815649 Publication Model: Print-Electronic Cited Medium: Internet ISSN: 1572-9389 (Electronic) Linking ISSN: 13869620 NLM ISO Abbreviation: Health Care Manag Sci Subsets: MEDLINE |
| Imprint Name(s): | Original Publication: Bussum, Netherlands : Baltzer Science Publishers, c1998- |
| Ιατρικοί όροι (MeSH): | Patient Discharge Summaries*/standards , Natural Language Processing* , Patient Discharge*, Humans ; Germany ; Retrospective Studies ; Systematized Nomenclature of Medicine ; International Classification of Diseases ; Electronic Health Records |
| Περίληψη: | The diagnosis section in hospital discharge summaries plays a critical role in ensuring continuity of care by providing essential diagnostic information and a succinct summary of a patient's condition to subsequent caregivers. However, the lack of standardized structure and content can lead to incomplete, ambiguous, or inaccurate documentation, potentially compromising patient safety. This study takes a foundational step toward standardizing the diagnosis section in German, and potentially international, discharge summaries by developing a taxonomy of structural and content elements and examining the use of standardized terminologies and abbreviations. We conducted a retrospective analysis of 436 de-identified discharge summaries from 112 hospitals across 12 German states. A structured taxonomy development process was applied, supported by natural language processing, to examine structural and content elements as well as the use of standardized terminologies (SNOMED-CT, ICD-10 codes) and abbreviations. The resulting taxonomy for diagnosis sections comprises 87 distinct characteristics across three meta-dimensions: structure, content, and levels of detail. The analysis revealed limited adoption of standardized terminologies; only 8.1% of terms conformed to SNOMED-CT, and only 14.2% of diagnosis sections included ICD-10 codes. Abbreviations appeared in 92% of diagnosis sections, constituting 14.5% of all words, many of which were obscure or infrequently used. These findings underscore the urgent need for a standardized, interoperable, and clinically meaningful diagnosis section to support continuity of care and data-driven healthcare. The proposed taxonomy offers a foundational framework for future standardization efforts by providing structural and content "design options." (© 2025. The Author(s).) |
| Competing Interests: | Declarations. Ethics approval: This study has been reviewed by the ethics committee of the [blinded] (Number: [blinded]) and no ethical or professional concerns were raised. The study was performed in line with the principles of the 1964 Declaration of Helsinki. The manuscript does not contain patient data. Conflict of interest: This study was supported by the internal research fund of the Faculty of Health, School of Medicine, Witten/Herdecke University, Germany (Project IFF 2024–80). Julian Frings receives financial support through a doctoral scholarship from the German Academic Scholarship Foundation. The funders played no role in study design, data collection, analysis and interpretation of data, or the writing of this manuscript. |
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| Contributed Indexing: | Keywords: Clinical documentation standards; Content and structure; Diagnosis section; Electronic discharge summary; Natural language processing; Taxonomy |
| Entry Date(s): | Date Created: 20251029 Date Completed: 20251227 Latest Revision: 20251231 |
| Update Code: | 20260130 |
| PubMed Central ID: | PMC12743709 |
| DOI: | 10.1007/s10729-025-09732-8 |
| PMID: | 41160294 |
| Βάση Δεδομένων: | MEDLINE |
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