GPT in Neurology Notes: A Case Study on Prompt Refinement
Creators: name: Klotzman, Vanessa
Publisher: name: Zenodo
Year: 2023

description: This repository provides resources and guidance for automating the summarization of clinical encounter notes using OpenAI's GPT-4. It includes a Python script (<code>GPT-4-Chat.ipynb</code>), sample clinical notes from our study, and a document that illustrates the effect of prompt refinement on summarization outcomes, along with explanations on what the refined prompts are. <strong>Repository Contents:</strong> <strong>Clinical Notes:</strong> Sample clinical notes are provided for three distinct cases: Case 1: <code>1130.txt</code> – Hydrocephalus, Shunt Surgery Follow-up Case 2: <code>1547.txt</code> – Aneurysm, Complicated Recovery Case 3: <code>1026.txt</code> – Male Patient with Epilepsy <strong>Impact of Prompt Refinement on Summarization (<code>Impact-of-Prompt-Refinement.docx</code>):</strong> This document illustrates the variance in summarization outcomes between naive (original) and refined (improved) prompts across the three cases. <strong>GPT-4-Chat Notebook (<code>GPT-4-Chat.ipynb</code>):</strong> If you're interested in experimenting with prompt refinement, the <code>GPT-4-Chat.ipynb</code> file is included. In this notebook, you'll have the opportunity to interact with <code>GPT-4.ipynb</code>. When you run the program, you'll be greeted by the system, after which you'll need to input the desired prompt alongside the clinical note. <strong>Prompts for this study:</strong> Naive Prompt: Summarize this medical note Refined Prompt: <br> A clinical encounter refers to a medical visit or appointment between a<br> patient and a healthcare provider, such as a doctor, nurse practitioner, or physician assistant.During a clinical encounter, the healthcare provider typically evaluates the patient's medical history, performs a physical exam, orders and reviews diagnostic tests, and provides a diagnosis and treatment plan. The purpose of a clinical encounter is to provide medical care and improve the patient's health outcomes. Clinical encounters can occur in various settings, such as a doctor's office, clinic, hospital, or telehealth platform. Accurate and detailed documentation of the clinical encounter is vital for ensuring continuity of care and effective communication between healthcare providers. These are the following components that must be included in<br> a clinical encounter summarization. Reason for the visit: This should describe the patient's primary reason for seeking medical care, including any symptoms or concerns they have. History of present illness: This should provide a brief <br> summary of the patient's background and current symptoms,<br> as well as any relevant events that may have led up to their <br> current medical condition. This section typically includes the <br> patient's age, gender, and any significant medical history,<br> as well as a description of the present symptoms and how <br> they developed. It may also include information about any <br> recent events or activities that may have contributed to the <br> development of the symptoms, such as a recent injury or exposure<br> to an illness. Major findings: This should include any significant findings<br> from the physical exam, diagnostic tests, and lab tests. Patient information: This should include demographic information<br> such as the patient's name, age, gender, medical history,<br> allergies, and any other pertinent information. Medications: This should include any medications <br> prescribed or recommended by the healthcare provider. This <br> should include the name of the medication, dosage, <br> frequency, and any special instructions. Medical history: This should provide a comprehensive summary<br> of the patient's past medical conditions, surgeries, <br> hospitalizations, and family medical history. Physician information: This should list the healthcare <br> provider's name, specialty, and contact information. Follow-up instructions: This should outline any follow-up appointments, <br> tests, or other recommendations made by the healthcare provider. Course of treatment: This should include the expected trajectory of the patient's illness, the anticipated duration of treatment, or the specific steps that <br> the healthcare provider plans to take to manage the patient's condition. Outcome of the visit: This should describe the patient's response<br> to treatment and any changes in the patient's condition. Laboratory results: These are the findings from various laboratory<br> tests performed on the patient during the visit. Examples include <br> blood tests, urine tests, and microbiology cultures. These laboratory <br> tests can involve taking a sample of the patient's blood, urine,<br> or other bodily fluids or tissues, which is then analyzed <br> in a laboratory using various techniques and equipment. Imaging studies: They are non-invasive diagnostic tests that use<br> various techniques to produce images of the body's internal structures. <br> Examples of these tests include X-rays, CT scans, MRI scans, and <br> ultrasounds. Imaging studies can help identify abnormalities,<br> such as tumors or fractures, and diagnose and treat various <br> medical conditions. When documenting the results of imaging studies <br> in a clinical encounter note, it is important to include the date<br> that the test was performed and any relevant findings or <br> abnormalities that were detected. For example, a CT scan performed<br> on 5/15/21 may have revealed a minor fracture in the patient's <br> left tibia, while an MRI performed on 6/3/21 may have shown a <br> herniated disc in the patient's lumbar spine. By including <br> detailed information about imaging studies in the clinical <br> encounter note, healthcare providers can ensure that <br> other providers have access to accurate and up-to-date <br> information about the patient's condition and treatment plan.<br> Make sure to include all imaging tests. Other diagnostic tests: These are any other relevant diagnostic tests performed during the visit. Examples may include electrocardiograms (ECGs), pulmonary function tests, and biopsies. Follow-up appointments: This should include any scheduled<br> follow-up appointments, as well as any instructions for <br> the patient to schedule additional appointments. Patient education: This should include any instructions <br> or educational materials provided to the patient<br> during the visit. Please summarize the following clinical note in a list, and <br> include the components that I previously mentioned<br> that should be included in a clinical encounter summary.