Systems and methods for determining insufficient medical documentation

Abstract

This disclosure describes systems, devices, and techniques for automatically identifying missing or ambiguous information in documentation associated with a patient. For example, a system may include one or more computing devices configured to receive documentation comprising a plurality of documented items related to the patient and determine, based on at least a subset of the plurality of documented items, one or more undocumented items missing from the documentation, wherein the subset of the plurality of documented items and at least one of the one or more undocumented items define a medical concept. The one or more computing devices may also be configured to generate, based on the one or more undocumented items, a code representative of the one or more undocumented items and output the code.

What is claimed is: 
     
         1 . A computer-implemented method for determining insufficient medical information associated with a patient, the method comprising:
 receiving, by a computing device, documentation comprising a plurality of documented items related to the patient;   determining, by the computing device and based on at least a subset of the plurality of documented items, one or more undocumented items missing from the documentation, wherein the subset of the plurality of documented items and at least one of the one or more undocumented items define a medical concept;   generating, by the computing device and based on the one or more undocumented items, a code representative of the one or more undocumented items; and   outputting, by the computing device, the code.   
     
     
         2 . The method of  claim 1 , wherein the medical concept comprises one of a patient condition, a diagnosis of the patient, or a medical procedure performed on the patient. 
     
     
         3 . The method of  claim 1 , wherein determining the one or more undocumented items comprises:
 comparing the subset of the plurality of documented items to one or more predetermined sets of items;   identifying, based on the comparison, at least one of the one or more predetermined sets of items that comprises each documented item of the subset; and   selecting, for each of the identified at least one predetermined sets of items, at least one item not included in the subset as at least one of the one or more undocumented items.   
     
     
         4 . The method of  claim 1 , wherein:
 the medical concept is one of a plurality of medical concepts,   the one or more undocumented items comprise a plurality of undocumented items, and   each of the plurality of undocumented items are associated with a different one of the plurality of medical concepts.   
     
     
         5 . The method of  claim 1 , wherein at least one of the one or more undocumented items completes, with the subset of the plurality of documented items, a specific medical concept. 
     
     
         6 . The method of  claim 1 , wherein:
 the medical concept is a first medical concept,   at least one of the one or more undocumented items links a second medical concept and a third medical concept to the first medical concept, and   the second medical concept and the third medical concepts are defined by at least some of the plurality of documented items.   
     
     
         7 . The method of  claim 1 , wherein at least one of the one or more undocumented items confirms the medical concept, and wherein the medical concept was previously indicated and unconfirmed by the subset of the plurality of documented items. 
     
     
         8 . The method of  claim 1 , further comprising, responsive to receiving the code, generating, based on the code and for display, a query presenting at least one of the one or more undocumented items for selection by a user. 
     
     
         9 . A computerized system for coding medical documentation, the system comprising one or more computing devices configured to:
 receive documentation comprising a plurality of documented items related to the patient;   determine, based on at least a subset of the plurality of documented items, one or more undocumented items missing from the documentation, wherein the subset of the plurality of documented items and at least one of the one or more undocumented items define a medical concept;   generate, based on the one or more undocumented items, a code representative of the one or more undocumented items; and   output the code.   
     
     
         10 . The system of  claim 9 , wherein the medical concept comprises one of a patient condition, a diagnosis of the patient, or a medical procedure performed on the patient. 
     
     
         11 . The system of  claim 9 , wherein the one or more computing devices are configured to determine the one or more undocumented items by:
 comparing the subset of the plurality of documented items to one or more predetermined sets of items;   identifying, based on the comparison, at least one of the one or more predetermined sets of items that comprises each documented item of the subset; and   selecting, for each of the identified at least one predetermined sets of items, at least one item not included in the subset as at least one of the one or more undocumented items.   
     
     
         12 . The system of  claim 9 , wherein:
 the medical concept is one of a plurality of medical concepts,   the one or more undocumented items comprise a plurality of undocumented items, and   each of the plurality of undocumented items are associated with a different one of the plurality of medical concepts.   
     
     
         13 . The system of  claim 9 , wherein at least one of the one or more undocumented items completes, with the subset of the plurality of documented items, a specific medical concept. 
     
     
         14 . The system of  claim 9 , wherein:
 the medical concept is a first medical concept,   at least one of the one or more undocumented items links a second medical concept and a third medical concept to the first medical concept, and   the second medical concept and the third medical concepts are defined by at least some of the plurality of documented items.   
     
     
         15 . The system of  claim 9 , wherein at least one of the one or more undocumented items confirms the medical concept, and wherein the medical concept was previously indicated and unconfirmed by the subset of the plurality of documented items. 
     
     
         16 . The system of  claim 9 , wherein the one or more computing devices are configured to, responsive to receiving the code, generate, based on the code and for display, a query presenting at least one of the one or more undocumented items for selection by a user. 
     
     
         17 . The system of  claim 9 , wherein the one or more computing devices comprises:
 a documentation insufficiency coding module configured to:   receive the documentation comprising a plurality of documented items related to the patient;   determine, based on the at least a subset of the plurality of documented items, one or more undocumented items missing from the documentation; and   generate, based on the one or more undocumented items, the code representative of the one or more undocumented items.   
     
     
         18 . A computer-readable storage medium comprising instructions that, when executed, cause one or more processors to:
 receive documentation comprising a plurality of documented items related to the patient;   determine, based on at least a subset of the plurality of documented items, one or more undocumented items missing from the documentation, wherein the subset of the plurality of documented items and at least one of the one or more undocumented items define a medical concept;   generate, based on the one or more undocumented items, a code representative of the one or more undocumented items; and   output the code.   
     
     
         19 . The computer-readable storage medium of  claim 18 , wherein the medical concept comprises one of a patient condition, a diagnosis of the patient, or a medical procedure performed on the patient. 
     
     
         20 . The computer-readable storage medium of  claim 18 , wherein the instructions that cause the one or more processors to determine the one or more undocumented items comprise instructions that cause the one or more processors to:
 compare the subset of the plurality of documented items to one or more predetermined sets of items;   identify, based on the comparison, at least one of the one or more predetermined sets of items that comprises each documented item of the subset; and   select, for each of the identified at least one predetermined sets of items, at least one item not included in the subset as at least one of the one or more undocumented items.