Natural procedure labels controlled for coding

摘要

A computer-based system and method are described for generating a natural procedure label to summarize a clinical procedure description recorded into the system by a physician. The system and method manipulate a set of database records comprising medical content which is naturally descriptive of clinical procedures and which is controlled for coding to generate the natural procedure label and its corresponding non E & M Current Procedure Terminology (CPT) code during the recording the procedure description. To support the generation of a set of said natural procedure labels, the system and method provide interchangeable, connected, ontologically-based medical procedure database cartridges of medical content terms and rules that naturally describe constrained procedure representations for clinical procedure descriptions.