English output of the physical examination in an automated medical record

Abstract

As part of the long-term project to create a medical information system for the University of Tennessee Memorial Research Center and Hospital, a computerized patient record is being developed. The physical examination portion of the medical record has been automated with software written in the MUMPS programming language. The present package allows a physician at a computer terminal to input (in a questionnaire format) physical examination findings which are then encoded into highly compressed alphanumeric strings and recorded unambiguously in a tree-structured data base. This paper describes the generation of conveniently readable output from the structures which resulted from the questionnaire. The English phrase output, rich with modifiers and multiple-level descriptors, is clear, concise and convenient to use.