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Related Concept Videos

Methods of Documentation I: Source-Oriented Records01:18

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Source-oriented records, or SOR, are medical record-keeping organized by the data source. The SOR system was first developed in the mid-1900s to organize the growing patient data in hospitals and other healthcare facilities.
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Key Attributes include the following:
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Methods of Documentation V: CBE01:23

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Charting by Exception, or CBE, is a method of documentation used in healthcare, particularly in nursing, that focuses on documenting only significant or abnormal findings rather than recording every detail. This approach aims to streamline the documentation process, improve efficiency, and ensure that healthcare providers can quickly identify deviations from normalcy in patient assessments.
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Methods of Documentation VII: EMR01:30

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Electronic Medical Records (EMRs) primarily center around electronically documenting patients' health information within a single healthcare organization or practice. They contain essential clinical data related to a patient's medical history, diagnoses, medications, treatment plans, lab results, and other pertinent information relevant to the specific encounter or episode of care. EMRs are designed to streamline documentation and workflow processes within individual healthcare...
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Methods of Documentation II: POMR01:26

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The Problem-Oriented Medical Record (POMR) revolutionized medical record-keeping by introducing a systematic approach focusing on the patient's problems rather than merely listing symptoms. Dr. Lawrence Weed's introduction of this method in the 1960s marked a significant advancement in medical documentation. The POMR framework consists of four key components: the database, problem list, plan of care, and progress notes.
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Documentation in Long-Term and Home Healthcare Setting01:29

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Documentation in long-term care facilities and home healthcare settings is crucial for ensuring continuous, coordinated, and comprehensive care for patients. Each setting has its specific documentation processes and tools:
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Methods of Documentation VI: Case Management Model01:15

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The case management model is a multidisciplinary approach that involves healthcare professionals from diverse disciplines, such as physicians, nurses, therapists, social workers, and pharmacists, working collaboratively to address the various needs of patients. Each healthcare professional brings unique expertise and perspectives, contributing to a more comprehensive understanding of the patient's condition and tailoring treatment plans accordingly.
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Updated: Mar 7, 2026

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Computer-based organisation and documentation in orthopaedics: 5 year's experience.

T Hess1, D Deimel1, R Fischer1

  • 1Orthopädische Universitätsklinik Homburg/Saar, Germany.

Der Orthopade
|March 2, 2017
PubMed
Summary
This summary is machine-generated.

Computer-assisted clinic management systems enhance surgical planning and documentation efficiency. This system, used for over 31,500 patients and 8,500 operations, demonstrates effective orthopedic clinic organization.

Keywords:
Key words Electronic Data Processing • Documenation • German health law • Classification

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Area of Science:

  • Orthopedic Surgery
  • Health Informatics
  • Hospital Administration

Background:

  • The orthopedic department at University Hospital Homburg/Saar has utilized a computer-based system since 1993.
  • The system integrates patient data management with specialized coding for ICD (International Classification of Diseases) and IKPM (Information, Communication, Planning, Management) digits.

Purpose of the Study:

  • To evaluate the effectiveness of a computer-assisted clinic management system in orthopedic surgery.
  • To assess the system's role in improving surgical planning and documentation.
  • To highlight the benefits of flexible software in meeting clinical and administrative needs.

Main Methods:

  • Implementation of a computer-based system utilizing DOS/Windows PCs within a Novell network.
  • Development of a combined database for patient data and a coding program for ICD and IKPM digits.
  • Extensive use of the system for managing 31,500 patients and 8,500 operations.

Main Results:

  • Computer-assisted clinic management proves to be an effective tool for surgeons in planning and documentation.
  • The system has been successfully applied to a large patient and operation volume.
  • A flexible software solution effectively addresses the requirements of both surgeons and administrative staff.

Conclusions:

  • Computer-assisted systems significantly enhance efficiency in orthopedic clinic organization and operation documentation.
  • The integration of patient data management and specialized coding improves workflow and data accuracy.
  • The hospital's intranet connectivity further supports data sharing and access to scientific networks and the internet.