Method for Implementing a Controlled Medical Vocabulary

摘要

A method of implementing a controlled vocabulary may include the steps of generating the controlled vocabulary by forming a list of medical terms and associated descriptions; creating a list of codes internal to the controlled vocabulary; and storing the codes, the medical terms, and the descriptions in a format suitable for use in the patient longitudinal electronic medical record environment. In addition, a sound wave may be captured as an electronic file, translated into text, and stored as a patient medical record event. The patient medical record event may be parsed for context and may be tagged with one or more source vocabularies, and a code internal to the source vocabulary may be provided. Event context and source vocabulary findings may then be used as discrete elements to add to the longitudinal patient electronic medical record environment.