| 摘要 |
An apparatus and method for forming medical records and a medical record formed thereby are provided. The apparatus preferably includes a voice input device for inputting free dictation of medical personnel, a voice processor responsive to the voice input device for processing the inputted voice and generating voice data therefrom, and a key term recognizer responsive to the voice processor for recognizing key medical terms freely dictated by the medical personnel. The key term recognizer preferably includes a key medical term database for storing a plurality of key medical terms therein. The apparatus preferably also includes a medical term matcher responsive to the key word recognizer for matching recognized key medical terms used by the medical personnel at least with patient conditions to thereby add additional data thereto and a medical record creator responsive to the medical term matcher for creating an actual patient medical record therefrom. A method of forming medical records preferably includes generating a plurality of key medical terms, recognizing the plurality of key medical terms responsive to a key medical term database having a plurality of key medical terms stored therein, matching recognized key medical terms used by the medical personnel at least with known patient conditions stored in a knowledge database so that the knowledge database assists in further describing the actual condition of the patient by adding additional data thereto, and creating an actual patient medical record responsive to the matched recognized key medical terms.
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