Words prediction based on N-gram model for free-text entry in electronic health records.

The process of documentation is one of the most important parts of electronic health records (EHR). It is time-consuming, and up until now, available documentation procedures have not been able to overcome this type of EHR limitations. Thus, entering information into EHR still has remained a challenge. In this study, by applying the trigram language model, we presented a method to predict the next words while typing free texts. It is hypothesized that using this system may save typing time of free text. The words prediction model introduced in this research was trained and tested on the free texts regarding to colonoscopy, transesophageal echocardiogram, and anterior-cervical-decompression. Required time of typing for each of the above-mentioned reports calculated and compared with manual typing of the same words. It is revealed that 33.36% reduction in typing time and 73.53% reduction in keystroke. The designed system reduced the time of typing free text which might be an approach for EHRs improvement in terms of documentation.