ChatGPT for Neurosurgical Documentation Assistance

ChatGPT assisted in the writing of discharge summaries and operative reports as evidenced by an impressive reduction in time spent as compared to standard speech recognition software. While promising, the optimal use cases and ethics of AI-generated medical writing remain to be fully elucidated and must be further explored in future studies 1).

Documentation is a critical component of neurosurgical practice, ensuring clear communication, continuity of care, and compliance with legal and institutional requirements. ChatGPT can enhance the efficiency, accuracy, and completeness of documentation by serving as an intelligent assistant for neurosurgeons. Here’s how:

—

### Applications of ChatGPT in Neurosurgical Documentation

#### 1. Operative Reports

  1. Automated Drafting: ChatGPT can generate detailed operative reports based on input data, including patient demographics, preoperative diagnosis, procedure performed, surgical findings, and postoperative plan.
  2. Templates: It can use standardized templates tailored to specific neurosurgical procedures (e.g., craniotomy, spinal fusion, tumor resection).
  3. Customization: Surgeons can customize reports by providing specific surgical details or preferences, ensuring personalized and accurate documentation.

#### 2. Discharge Summaries

  1. Comprehensive Summaries: ChatGPT can draft discharge summaries by synthesizing admission details, key interventions, progress notes, and follow-up recommendations.
  2. Patient-Centric Communication: It can create simplified versions of discharge instructions for patient understanding and compliance.

#### 3. Progress Notes

  1. SOAP Notes: ChatGPT can draft structured progress notes following the Subjective, Objective, Assessment, and Plan (SOAP) format.
  2. Integration with Rounds: It can summarize key updates during daily rounds, saving time for the medical team.

#### 4. Consultation Notes

  1. Rapid Note Generation: ChatGPT can create thorough consultation notes, including reason for referral, clinical findings, differential diagnosis, and recommendations.
  2. Evidence-Based Recommendations: It can suggest diagnostic tests or treatment options based on guidelines.

#### 5. Research and Academic Documentation

  1. Case Reports: ChatGPT can help structure and draft case reports, including a compelling abstract, background, case details, and discussion.
  2. Study Protocols: It can assist in drafting research protocols or Institutional Review Board (IRB) applications for neurosurgical studies.

#### 6. Administrative and Compliance Documentation

  1. Consent Forms: ChatGPT can generate informed consent documents with procedure-specific risks and benefits.
  2. Audit and Compliance Reports: It can assist in creating reports for hospital audits, quality assurance, and compliance tracking.

#### 7. Patient Communication

  1. Educational Handouts: ChatGPT can generate patient-friendly handouts explaining conditions, procedures, and postoperative care.
  2. Telemedicine Summaries: It can create documentation for virtual consultations, ensuring thorough and accurate records.

—

### Benefits of ChatGPT for Documentation 1. Time Efficiency: Automates repetitive tasks, freeing up time for patient care and decision-making. 2. Standardization: Ensures consistent and comprehensive documentation across cases and providers. 3. Accuracy: Reduces errors by generating complete and precise notes based on input data. 4. Customization: Adapts to individual or institutional preferences for documentation style and content.

—

### Limitations and Challenges - Input Dependency: The quality of output depends on the quality and specificity of input data. - Legal and Ethical Considerations: All generated documentation must be reviewed and approved by the physician to ensure compliance with legal standards. - Data Security: Strict measures are necessary to ensure patient confidentiality and compliance with HIPAA/GDPR regulations. - Complex Scenarios: ChatGPT may struggle with highly nuanced or complex cases without detailed clinician guidance.

—

### Future Directions - EHR Integration: Seamless incorporation into electronic health record systems to auto-populate fields and synchronize data. - Voice-to-Text Features: Enable real-time transcription and documentation during procedures or rounds. - Predictive Analytics: Use patient data to suggest likely postoperative outcomes, complications, or follow-up needs. - Institution-Specific Protocols: Tailor documentation to reflect regional or institutional standards and preferences.

By leveraging ChatGPT for neurosurgical documentation, clinicians can improve the quality and efficiency of their records while focusing more on patient care and critical decision-making.

1)
Dubinski D, Won SY, Trnovec S, Behmanesh B, Baumgarten P, Dinc N, Konczalla J, Chan A, Bernstock JD, Freiman TM, Gessler F. Leveraging artificial intelligence in neurosurgery-unveiling ChatGPT for neurosurgical discharge summaries and operative reports. Acta Neurochir (Wien). 2024 Jan 26;166(1):38. doi: 10.1007/s00701-024-05908-3. PMID: 38277081; PMCID: PMC10817836.