预先护理计划的讨论旨在指导未来的严重疾病护理。这些讨论可以通过在临床笔记、结构化表格和指示以及医嘱中进行记录，并记录在电子健康记录中。然而，大多数预先护理计划普及性研究仅考虑了结构化电子健康记录要素，忽略了笔记中现有的数据。我们旨在调查结构化和非结构化电子健康记录数据源中预先护理计划文档的综合性和准确性。我们评估了从三个不同的医疗保健系统中抽取的435名癌症患者的电子健康记录中的结构化和非结构化的预先护理计划文档。我们通过手工注释书面文件和扫描到电子健康记录中的表格来提取结构化的预先护理计划文档。我们使用基于规则的自然语言处理软件对临床笔记中的预先护理计划关键词进行编码，然后进行准确性复查。与结构化预先护理计划方法（187例，占患者总数的42.9%）相比，非结构化方法发现了更多的预先护理计划文档实例（238例，占患者总数的54.7%）。此外，占所有有结构化预先护理计划文档的患者的16.6%仅有被判定为错误分类、不完整、空白、不可用或重复输入的错误文档。扫描进入电子健康记录的预先护理计划文档只代表了预先护理计划活动的有限视角。预先护理计划的研究和临床实践的测量应该综合利用非结构化数据的信息。版权所有©2023年。Elsevier Inc.出版。

Advance care planning discussions seek to guide future serious illness care. These discussions may be recorded in the electronic health record by documentation in clinical notes, structured forms and directives, and physician orders. Yet, most studies of advance care planning prevalence have only examined structured electronic health record elements and ignored data existing in notes. We sought to investigate the relative comprehensiveness and accuracy of ACP documentation from structured and unstructured electronic health record data sources. We evaluated structured and unstructured advance care planning documentation present in the electronic health records of 435 patients with cancer drawn from three separate healthcare systems. We extracted structured advance care planning documentation by manually annotating written documents and forms scanned into the electronic health record. We coded unstructured advance care planning documentation using a rule-based natural language processing software that identified advance care planning keywords within clinical notes and was subsequently reviewed for accuracy. The unstructured approach identified more instances of advance care planning documentation (238, 54.7% of patients) than the structured advance care planning approach (187, 42.9% of patients). Additionally, 16.6% of all patients with structured advance care planning documentation only had documents that were judged as misclassified, incomplete, blank, unavailable, or a duplicate of a previously entered erroneous document. Advance care planning documents scanned into electronic health records represent a limited view of advance care planning activity. Research and measures of clinical practice with advance care planning should incorporate information from unstructured data.Copyright © 2023. Published by Elsevier Inc.