[Technical implementation of an EDP based process documentation system for routine use in inpatient medical...

Since 1994 the German Pension Fund has developed a systematic and centralized quality control system. Central components are a structural analysis of hospitals and rehab centers, a peer review instrument based on the treatment protocols and reports, and an outcome questionaire based on a follow-up 6 months after discharge from hospital or the rehab center. In order to improve the well established peer review instrument a new protocol document named RehaProDok was established. Based on a preexisting electronic report system, the new document can be generated automatically. Without additional work for the hospital or center a short discharge report for physicians is produced with this instrument. The use of ICF is strengthened by standardized use of rehab goals and its systematic input into the final report, which in turn improves patient orientation. Other quality important features (e. g. Team approach, changes in therapy protocol due to progress within of the rehab process) may be examined directly and added in the future. All technical improvements can be easily adapted to other clinical information systems.