A Method for Automatic Coding of Medical Information in Patient Records

Abstract

An automated method for coding hospital patient records is described, which uses a combination of simple computer programs and a structured dictionary. The system accepts unrestricted medical language in French as input, and generates code combinations which represent the semantic values of the original statements. The coding structure is the trial version of the Systematized Nomenclature of Medicine (SNOMED) [9], A prototype system has been developed from a 20,000 word corpus of obstetrical and gynecological data, recorded from patient records written by French-speaking Quebec physicians. Preliminary test results on a small sample show that the system generates accurate codes and code combinations for 97.9% of the data tested. The programs were written in Fortran IV and implemented on a DEC PDP-9 computer. The dictionary keys are word segments and the entries contain operators, word segments and SNOMED codes. The dictionary structure permits a single entry to generate multiple SNOMED codes and to handle the types of linguistic paraphrase found in hospital records. The SNOMED codes and code combinations constitute a metalanguage which provides the means for data compression and uniform representation of natural language medical data.