CPM Blog

SecTag -- Tagging Clinical Note Section Headers

Clinical notes are often divided into sections, or segments, such as "history of present illness" or "past medical history." These sections often have subsections as well, such as the "cardiovascular exam" section of the "physical exam." One can gain greater understanding of clinical notes by recognition of the section in which a concept lives. For instance, both a "past medical history" and the "family medical history" sections can contain a list of diseases, but the context decribes very different import to the patient about whom the note was written.

Homer Warner Award, AMIA 2008

A paper on a terminology of section headers received the 2008 Homer Warner Award: Denny JC, Miller RA, Johnson KB, Spickard A 3rd. Development and evaluation of a clinical note section header terminology. AMIA Annu Symp Proc. 2008 Nov 6:156-60.