Method for implementing a controlled medical vocabulary

1. A method of implementing a controlled vocabulary in a longitudinal electronic medical record, comprising:

generating a first instance of a plurality of data objects during a first encounter, said plurality of data objects comprising data elements further comprising a first instance identifier and temporal identifiers;

linking a data object in said first instance to a summarization reference with a pointer, where the plurality of data objects and the summarization reference are related as part of a directed graph data structure;

creating an additional instance of a plurality of data objects during a later encounter, said additional instance of a plurality of data objects comprising data elements further comprising an additional instance identifier and temporal identifier;

providing continuity for said plurality of data objects of said first instance over time;

capturing said controlled vocabulary using a computer by forming a list of medical terms and list of associated descriptions;

creating a list of codes internal to said controlled vocabulary;

storing said codes, said medical terms, and said descriptions using a computer in a format suitable for use in the longitudinal electronic medical record; and

tagging elements within a domain within the longitudinal medical record with said controlled vocabulary;

wherein said controlled vocabulary maps to at least one of a reference terminology or an administrative terminology; and

wherein said providing step comprises tracking a relationship between said data object of said first instance and a data object of said additional instance.

2. A method according to claim 1 , wherein each domain within said longitudinal electronic medical record is tagged with said elements of controlled vocabulary and said codes.

3. A method according to claim 1 , wherein said medical terms are derived for substantially all parts of a patient medical record, comprising problems, medications, plans, history items, and subjective findings.

4. A method according to claim 1 , wherein elements of said controlled vocabulary in one domain within said longitudinal electronic medical record are in a many-to-many relationship with elements of said controlled vocabulary in a second domain.

5. A method according to claim 1 , wherein said method reduces a need for data cleansing.

6. A method according to claim 1 , wherein said generating uses a plurality of standard vocabularies applied to a plurality of electronic medical record fields, said fields including:

insurance information lists,

allergy lists,

problem lists,

test history lists, and

medication lists.

7. A method according to claim 1 , wherein said creating produces administrative codes.

8. A method according to claim 1 , wherein said creating produces coder-specific language.

9. A method according to claim 1 , wherein said creating produces patient-friendly terms.

10. A method according to claim 1 , wherein said creating produces billing codes.

11. A method according to claim 1 , further comprising implementing decision support with patient information tagged with interface terminology.

12. A method of processing a sound wave and correlating it with a source vocabulary, comprising:

capturing, using a computer, a sound wave as an electronic file;

translating, using a computer, said electronic file into text;

storing said text as a patient medical record using a computer with directed graph database storage;

tagging said patient medical record with a source vocabulary;

mapping said source vocabulary to at least one of a reference terminology or an administrative terminology; and

providing a code internal to said source vocabulary.

13. A method according to claim 12 , wherein said source vocabulary comprises controlled medical vocabulary terms.

14. A method according to claim 12 , wherein said tagging comprises capturing a clinical intent and said providing comprises capturing a classification among a plurality of concepts.