Medical documentation and record management in Germany

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.

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.