Bell D S, Greenes R A, Doubilet P
Decision Systems Group, Harvard Medical School, Brigham and Women's Hospital, Boston, Massachusetts.
Proc Annu Symp Comput Appl Med Care. 1992:789-90.
Ultra-STAR (Ultrasound Structured Attribute Reporting) allows a sonographer to record reports using a hierarchic standardized vocabulary. Reports are constructed interactively by using checkboxes and radio buttons in a graphical user interface to select concepts from the vocabulary. Concepts are presented in small windows that open when needed to record further detail. Preliminary reports are printed for the referring physician. Reports are later finalized by an attending radiologist and uploaded to the hospital's information system. Clinicians involved so far prefer an outline report to a natural language format.
超声结构化属性报告(Ultra-STAR)允许超声检查医师使用分层标准化词汇记录报告。通过在图形用户界面中使用复选框和单选按钮从词汇表中选择概念来交互式构建报告。概念以小窗口呈现,需要记录更多细节时会打开这些窗口。初步报告打印出来供转诊医生使用。报告随后由主治放射科医生定稿并上传到医院信息系统。到目前为止,参与的临床医生更喜欢提纲式报告而非自然语言格式。