Checking a structured pathology report for completeness of content using terminological knowledge

Abstract

Structuring of information helps people to gain a quick overview of complex issues and facilitates the transfer of large amounts of data. In the medical field, such data are transferred using defined standards (HL7 1 , DICOM 2 ) or in conjunction with terminology systems (ICD-10 3 , LOINC 4 , SNOMED CT 5 ). This paper focuses on the structuring of diagnostic reports in the field of anatomic pathology. It describes how to make the content of these reports semantically understandable for machines. Finally, it will be shown that structured pathology reports can be checked for completeness of content in a computerized way by using terminological knowledge. For this purpose, an ontology has been designed that describes the subdomain of reporting a radical prostatectomy specimen.