Document (#31079)

Author

Gaus, W.
Kaluscha, R.

Title

Maschinelle inhaltliche Erschließung von Arztbriefen und Auswertung von Reha-Entlassungsberichten

Source

Information und Sprache: Beiträge zu Informationswissenschaft, Computerlinguistik, Bibliothekswesen und verwandten Fächern. Festschrift für Harald H. Zimmermann. Herausgegeben von Ilse Harms, Heinz-Dirk Luckhardt und Hans W. Giessen

Imprint

München : Saur

Year

2006

Pages

S.159-168

Abstract

Schon Hippokrates empfahl den Ärzten, Krankenakten zu führen. Heute ist die detaillierte Dokumentation eine Standespflicht der Ärzte [Gaus et al 1999]. Diese Dokumentationen medizinischer Behandlungen bergen einen riesigen und wertvollen Erfahrungsschatz. Informationen zu Therapien und Behandlungsergebnissen, die in Studien erst mühsam erhoben werden müssten, sind bereits in der Routinedokumentation wie Operations- und Entlassungsberichten oder Arztbriefen zahlreich vorhanden. Mit der Einführung der elektronischen Datenverarbeitung in der Medizin liegen diese Informationen seit einigen Jahren auch maschinenlesbar vor, so dass ein Haupthemmnis für die Nutzung dieser Dokumentationen, nämlich die mühsame manuelle Aufbereitung der Papierakten, entfällt. Während die formale Erschließung nach Patientenmerkmalen wie Name und Geburtsdatum von den Krankenhaus- bzw. Praxisinformationssystemen heutzutage gut gelöst ist, bleibt die inhaltliche Erschließung dieser Dokumentationen schwierig, da nur wenige Informationen in strukturierter oder intellektuell indexierter Form vorliegen [Leiner et al. 2003]. Auch wenn nach der Einführung der Fallpauschalen (diagnosis related groups, DRG) in den Krankenhäusern die Diagnosen nach ICD-10 verschlüsselt werden, besteht ein Großteil der Informationen weiterhin aus freiem Text, dessen computerbasierte Erschließung aufgrund der Komplexität menschlicher Sprache nicht trivial ist. Zu diesen medizinischen Texten gehören u.a. Gutachten, verbal beschriebene (Differential-) Diagnosen, vielfältige Untersuchungs- und Befundberichte, Visitenblätter, Operationsberichte und der Arztbrief bzw. Entlassungsbericht. Arztbrief und Entlassbericht dienen der Information des einweisenden oder weiterbehandelnden Arztes (z.B. Hausarzt) über das, was mit dem Patienten geschehen ist, und geben Empfehlungen zur Weiterbehandlung. Sie fassen eine (stationäre) Behandlung epikritisch - also nachdem die Krankheit überwunden ist, im Rückblick - zusammen und geben einen Überblick über Anamnese (Vorgeschichte), Beschwerden und Symptome, die eingesetzten diagnostischen Verfahren, die gestellte(n) Diagnose(n), Therapie, Verlauf, Komplikationen und das erzielte Ergebnis. Sie haben somit eine ähnliche Funktion wie das Abstract in der Literaturdokumentation, oft wird eine Kopie in der Krankenakte obenauf abgelegt. Zumindest in Universitätskliniken möchten wissenschaftlich arbeitende Ärzte auch unter inhaltlichen Gesichtspunkten auf die Krankenakten zugreifen können, z.B. die Krankenakten aller Patienten mit einer bestimmten Diagnose einsehen, exzerpieren und die exzerpierten Daten auswerten. Auch bei der Suche nach ähnlichen Fällen oder im Bereich der Aus- und Fortbildung hilft eine inhaltliche Erschließung weiter. So könnte etwa ein Assistenzarzt, der im Rahmen seiner Weiterbildung demnächst Sonografien des Kniegelenkes durchzuführen hat, sich vorhandene Berichte von solchen Sonografien anschauen und sich so über relevante Untersuchungstechniken und Befunde vorab informieren.

Theme

Automatisches Indexieren

Field

Medizin

Location

D

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5. Wartena, C.; Golub, K.: Evaluierung von Verschlagwortung im Kontext des Information Retrievals (2021) 0.12

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