From the Department of Orthopaedic Surgery, University of Chicago, Chicago, IL.
J Am Acad Orthop Surg. 2024 Feb 1;32(3):123-129. doi: 10.5435/JAAOS-D-23-00474. Epub 2023 Nov 17.
INTRODUCTION: Clinical documentation is a critical aspect of health care that enables healthcare providers to communicate effectively with each other and maintain accurate patient care records. Artificial intelligence tools, such as chatbots and virtual assistants, have the potential to assist healthcare providers in clinical documentation. ChatGPT is an artificial intelligence conversational model that generates human-like responses to text-based prompts. In this study, we sought to investigate ChatGPT's ability to assist with writing a history of present illness based on standardized patient histories. METHODS: A blinded, randomized controlled study was conducted to compare the use of typing, dictation, and ChatGPT as tools to document history of present illness (HPI) of standardized patient histories. Eleven study participants, consisting of medical students, orthopaedic surgery residents, and attending surgeons, completed three HPIs using a different documentation technique for each one. Participants were randomized into cohorts based on the type of documentation technique. Participants were asked to interview standardized patients and document the patient's history of present illness using their assigned method. RESULTS: ChatGPT was found to be intermediate for speed; dictation was fastest, but produced markedly longer and higher quality patient histories based on Physician Documentation Quality Instrument score compared with dictation and typing. However, ChatGPT included erroneous information in 36% of the documents. Poor agreement existed on the quality of patient histories between reviewers. DISCUSSION: Our study suggests that ChatGPT has the potential to improve clinical documentation by producing more comprehensive and organized HPIs. ChatGPT can generate longer and more detailed documentation compared with typing or dictation documentation methods. However, additional studies are needed to investigate and address concerns regarding privacy, bias, and accuracy of information.
简介:临床文档是医疗保健的一个关键方面,它使医疗保健提供者能够彼此有效地沟通,并保持准确的患者护理记录。人工智能工具,如聊天机器人和虚拟助手,有可能协助医疗保健提供者进行临床文档记录。ChatGPT 是一种人工智能对话模型,它能够对基于文本的提示生成类似人类的响应。在这项研究中,我们试图研究 ChatGPT 协助基于标准化患者病史编写现病史的能力。
方法:一项盲法、随机对照研究比较了使用打字、口述和 ChatGPT 作为工具来记录标准化患者病史的现病史(HPI)的能力。11 名研究参与者,包括医学生、骨科住院医师和主治医生,使用不同的文档技术完成了三个 HPI。参与者根据文档技术的类型随机分为两组。参与者被要求采访标准化患者,并使用他们分配的方法记录患者的现病史。
结果:ChatGPT 的速度中等;与打字和口述相比,口述最快,但根据医师文档质量工具评分,产生的患者病史更长、质量更高。然而,ChatGPT 在 36%的文档中包含错误信息。审稿人对患者病史的质量存在较差的一致性。
讨论:我们的研究表明,ChatGPT 有可能通过生成更全面和更有条理的 HPI 来改善临床文档记录。ChatGPT 可以生成比打字或口述文档方法更长、更详细的文档。然而,需要进一步的研究来调查和解决关于隐私、偏见和信息准确性的问题。
J Am Acad Orthop Surg. 2024-2-1
Front Med (Lausanne). 2023-12-13
Am J Obstet Gynecol. 2024-8
J Med Internet Res. 2025-8-6
Psychiatr Res Clin Pract. 2025-3-27
Unfallchirurgie (Heidelb). 2025-5-12