Coherence

The issues addressed in medical record tend to follow a defined order. This can be proved by excising a fragment of text that encompasses an issue and observing that clinicians tend to replace it in its original location. The principle of Coherence holds that:

Every lexeme query has one appropriate location in a professional report.

The implication of this is that all lexeme queries can be organized in coherent order.

Context

The context within which the report is written determines the layout and major headings of the report. The context consists of the type of medical interaction, the role of the author of the report and the characteristics of the patient. An orthopedist seeing a child in an emergency treatment center needs a radically different set of major sections in the report than a radiologist reading mammograms. The context generates a starting set of predicants.

Level

Some lexeme queries deal with topics in fine detail. They have a high hierarchical level. Other lexeme queries are more general, and have a low level. Each lexeme query has an associated level. Each time a user selects a lexeme response, it sets the system’s level. The system only presents lexeme queries if its level is equal to, or lower than the system’s current level.

Lexeme

is the least unit of information, generally expressed as a fragment of meaningful text. Lexeme refers to the information itself, not to the text used to express it. Lexemes are most usefully regarded as the combination of a lexeme query and a lexeme response.

Lexeme query

Is an issue or topic that is addressed in a professional report. It can be framed as a (hypothetical) question. Professional reports can be analyzed as a stream of lexeme queries. Each Lexeme query is associated with its own handful of relevant lexeme responses.

Lexeme response

Is an answer to its associated lexeme query. Lexemes responses can expressed in any number of styles and languages, including computer codes.

Lexicon Editor

Refers to the computer program that enables the user to add or revise entries in the lexicon.
Loop-back. Special programming enables the system to process though the same set of lexeme queries more than once. For instance, suppose a patient comes in with both an arm and leg injury. Each injury needs to user to assess the injury for bleeding, pain and signs of fracture. On completing the consideration of the arm injury the loop back procedure can send the system back to address the leg injury. The lexeme response that initiates the loop back will start the loop at the lexeme query which has level one lower than its level.

Predicance

Every well written report exhibits the phenomenon of predicance. The Principle of Predicance holds that

No issue is addressed in the professional report unless called for either by the context of the report, or by responses lodged earlier in the report.

For instance, in a medical report, the consideration of treating gout is only explored in detail if the clinician selects a lexeme response raising the issue of gout. In the absence of this selection, the issue of gout would only be raised if the context of the report suggests gout (such as a rheumatology consult for a patient with arthritis).

Predicants

Are computer tags that are associated with relevant lexeme queries. Every lexeme query has at least one associated predicant. When selected, a lexeme response may issue new predicants. The computer system maintains a list of the predicants set during the creation of a document. It adds to this list when new predicants are issued by selecting lexeme responses or by the context.

No lexeme query is presented to the user unless at least one of its associated predicants has a match in the system’s predicant list

Level

Some lexeme queries deal with topics in fine detail. They have a high hierarchical level. Other lexeme queries are more general, and have a low level. Each lexeme query has an associated level. Each time a user selects a lexeme response, it sets the system’s level. The system only presents lexeme queries if its level is equal to, or lower than the system’s current level.

LEXeNOTES

Refers to the computer program that enables the user to prepare a report by selecting lexeme responses.