Form-based clinical input from a structured vocabulary: initial application in ultrasound reporting.

Abstract

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.