Concepts Issues and Standards. Application of Controlled Medical Vocabularies: A Controlled Vocabulary Framework for Report Generation in Bone-Scintigraphy

摘要

Diagnostic studies resulting in qualitative findings are an important source of patient data. Every study domain can be associated with its respective terminology for representing and verbalizing findings. A method is proposed for acquiring the study-specific terminology in a diagnostic imaging domain by sublanguage analysis. Crucial semantical categories are anatomical locations, study-specific phenomena and interpretations. Structuring principles are given for organizing the domain objects into a controlled vocabulary framework that can be used for study documentation and report generation. It is described how an adaptive user interface can be designed that allows the composition of complex findings by term selection. Text generation strategies are outlined for verbalizing findings into acceptable report formats. The model has been applied to bone-scintigraphy, a diagnostic imaging procedure of nuclear medicine.