Digital Commons at Loyola Marymount University and Loyola Law School
Abstract
In traditional radiology practice, reports are typically dictated and then transcribed.? While the free-text reports represent the semantic knowledge interpreted and conveyed by a physician, the information can be hard to access. The advantages of representing medical data in a structured format using standard terminology are clearly recognized. These include the ability to implement a standardized electronic medical record, automatically invoke medical guidelines when appropriate, and conduct outcomes research. Standard structured reports facilitate intelligent indexing, searching, and retrieval of documents from clinical databases. Recent attempts have been made in the industry to enable structured data entry using preformatted templates, but these have yet to gain widespread acceptance.1,2 These preformatted templates do not necessarily use standard nomenclature and tend to disturb a clinician’s normal workflow. This paper presents a prototype system that incorporates the benefits of both dictated free-text reports and standard, structured reports
