Self-Documenting Structured Reports using Open Information Standards

Structured reporting systems use standardized data elements and predetermined data-entry formats to record observations. This article describes a system for structured data entry and reporting that generates reports encoded in the Standard Generalized Markup Language (SGML), an open, internationally accepted standard for document interchange. The structured report is self-documenting: it includes a definition of its allowable data field and values encoded as a report-specific SGML document type definition (DTD). By linking its reporting concepts with those of external vocabularies such as the UMLS Metathesaurus, this system can create open, universally comprehensible structured reports.