Moore G W, Berman J J
Laboratory Service, Veterans Affairs Medical Center, Baltimore, Maryland.
Proc Annu Symp Comput Appl Med Care. 1991:973-5.
Automated coding of surgical pathology reports is demonstrated. This public-domain translation software operates on surgical pathology files, extracting diagnoses and assigning codes in a controlled medical vocabulary, such as SNOMED. Context-sensitive translation algorithms are employed, and syntactically correct diagnostic items are produced that are matched with controlled vocabulary. English-language surgical pathology reports, accessioned over one year at the Baltimore Veterans Affairs Medical Center, were translated. With an interface to a larger hospital information system, all natural language pathology reports are automatically rendered as topography and morphology codes. This translator frees the pathologist from the time-intensive task of personally coding each report, and may be used to flag certain diagnostic categories that require specific quality assurance actions.
展示了手术病理报告的自动编码。这种公共领域的翻译软件可处理手术病理文件，提取诊断信息并使用诸如SNOMED之类的受控医学词汇分配代码。采用上下文敏感的翻译算法，生成语法正确的诊断项目并与受控词汇进行匹配。对巴尔的摩退伍军人事务医疗中心一年多来登记的英文手术病理报告进行了翻译。通过与更大的医院信息系统的接口，所有自然语言病理报告都自动呈现为部位和形态代码。该翻译器使病理学家从亲自为每份报告编码这一耗时的任务中解脱出来，并可用于标记某些需要特定质量保证措施的诊断类别。
