Diagnosis decoded: a taxonomy and natural language processing analysis of the diagnosis section in German hospital discharge summaries.

ABSTRACT: The diagnosis section in hospital discharge summaries plays a critical role in ensuring continuity of care by providing essential diagnostic information and a succinct summary of a patient's condition to subsequent caregivers. However, the lack of standardized structure and content can lead to incomplete, ambiguous, or inaccurate documentation, potentially compromising patient safety. This study takes a foundational step toward standardizing the diagnosis section in German, and potentially international, discharge summaries by developing a taxonomy of structural and content elements and examining the use of standardized terminologies and abbreviations. We conducted a retrospective analysis of 436 de-identified discharge summaries from 112 hospitals across 12 German states. A structured tax

SUBMITTER: Frings J 

PROVIDER: S-EPMC12743709 | biostudies-literature | 2025 Dec

REPOSITORIES: biostudies-literature