Nomenclature

Overview
The CytoBase Electronic Medical Record stores the medical information content of Pap reports in coded form.  When reports are prepared for human interpretation (either on paper or on-screen), these codes are transformed into textual phrases by means of a dictionary.  An example dictionary is presented below. This dictionary has been adapted from the Bethesda Nomenclature for cervical cytology reporting.  However, the CytoBase EMR does not place any restrictions whatsoever on the choice of nomenclature that could to be used in different implementations. 

The general coding mechanism is referred to as the CytoBase Abstract Coding Syntax.  The coding syntax is both machine readable and hierarchical.  This allows machine interpretation of Pap reports to assist in automated decision making processes such as targeting women for follow-up intervention, determining a women’s health status, or distinguishing between specimen adequacy, recommendations, or clinical information.  The hierarchical structure also permits extensions of medical concepts in response to advances in diagnostic sciences.

Each code takes the form “N.N.N ….” where each N represents a numerical value corresponding to a hierarchical concept (node) or item of information.  The number of nodes within the hierarchy is not limited, nor is the number of information items per node.  However, it is useful to “fix” the node values to a set number of digits to improve processing and query time (e.g. 04.03.08 uses 2-digits for each node).  For example, cervical cytology implementations are usually restricted to 2-digit node/item values since these seems to adequately cover the complete range of data to be stored.