Abstract: A computing device-based system and method are described for generating a medical 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 clinically accurate diagrams which are naturally descriptive to document a medical procedure. To support the generation of a set of said medical procedure descriptions, the system and method provide interchangeable, connected, ontologically-based medical procedure database cartridges of medical content terms, rules, and diagrams that naturally describe constrained procedure representations for clinical procedure descriptions.

Abstract: A method and system for clinical order entry and decision support are provided. The system and method allow physicians to input orders directly in clinical shorthand. The system presents high-probability choices for order action, determination of clinical context and possible problem solutions. The choices reflect current medical research, patient-specific information and standard practices of other physicians and/or administrators. Selections or edits to the presented choices can be entered quickly and easily, thereby allowing automated generation of complete orders needed to carry out the decisions made. In this way, medical decisions can be made and executed in a fast, efficient and standardized manner.