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Medical documentation and record management in Germany.

G H Oeffen1

  • 1MEDOC, Tarzana, CA.

Journal (American Medical Record Association)
|September 6, 1991
PubMed
Summary
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This paper details the adaptation of American medical record systems for a German university hospital. The author's foundational design became German law, influencing health record practices nationwide.

Area of Science:

  • Health Informatics
  • Medical Record Systems
  • International Healthcare Policy

Background:

  • The establishment of a new university medical center in Berlin in the mid-1960s necessitated the adaptation of existing medical record systems.
  • American medical record concepts, policies, procedures, and technology were identified as a potential model for the new center.

Purpose of the Study:

  • To describe the process of modifying American health record practices for implementation in a German university medical center.
  • To outline the resulting health record information practices in Germany based on this adaptation.

Main Methods:

  • The author was tasked with analyzing and adapting American medical record standards.
  • Implementation of modified concepts, policies, procedures, and technology within the new Berlin medical center.

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Main Results:

  • The adapted medical record design was successfully implemented and subsequently adopted as national law in Germany.
  • Established foundational health record information practices within the German healthcare system.

Conclusions:

  • The successful adaptation and legislative adoption of the modified American medical record system demonstrate the potential for cross-national transfer of healthcare information practices.
  • The described practices provide a historical perspective on the evolution of health record management in Germany.