CPC G06Q 10/10 (2013.01) [G06N 7/01 (2023.01); G06N 20/00 (2019.01); G06Q 50/22 (2013.01); G16H 50/20 (2018.01); G16H 50/30 (2018.01)] | 20 Claims |
1. A method, comprising:
receiving, by a clinical documentation improvement (CDI) system, real-time medical data from a data source, the real-time medical data comprising clinical data for a patient and documentation for a visit of the patient;
determining, by the CDI system based on the real-time medical data, a medical condition for the patient;
determining, by the CDI system utilizing the real-time medical data, a difference between portions of the real-time medical data and stored data items the CDI system has for the visit of the patient;
applying, by the CDI system, a machine learning diagnosis model to the portions of the real-time medical data to generate an under-documentation score, the under-documentation score representing a probability that the medical condition is clinically valid but is not sufficiently documented;
applying, by the CDI system, a machine learning documentation model to the stored data items the CDI system has for the visit of the patient to generate an over-documentation score, the over-documentation score representing a probability that the medical condition is documented but is not supported by the clinical data for the patient; and
generating, by the CDI system based at least in part on the under-documentation score and the over-documentation score, a CDI score for the visit of the patient.
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