title: Object-oriented controlled-vocabulary translator using TRANSOFT + HyperPAD.
abstract: 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.
authors.affiliation: Laboratory Service, Veterans Affairs Medical Center, Baltimore, Maryland.
authors.forename: G W
authors.initials: GW
authors.lastname: Moore
authors.forename: J J
authors.initials: JJ
authors.lastname: Berman
mesh_terms: D000465:Algorithms; D003628:Database Management Systems; D004282:Documentation; D016347:Medical Records Systems, Computerized; D009323:Natural Language Processing; D010340:Pathology, Surgical; D012984:Software; D014481:United States; D014493:United States Department of Veterans Affairs