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Development of a standardised computer-based documentation system for diagnoses and medical performance in
D Deimel1, E Messer2, H-G Thielemann3
1Orthopädische Klinik, Universitätsklinikum Mannheim, Germany.
Introduction:
Increasing demands on quality assurance und medical performance documentation require an immedate and evaluable documentation in the outpatients' department. Presentation of a new computer-based diagnostic system for reporting and medical performance documentation.
Methods:
Development and initial application of the system in three big orthopeadical or traumatological hospitals. Judegements about the feasibility of immediate documentation in outpatients' departments.
Results:
Presentation of an outpatients' departments diagnostic system with textblock-oriented anamnesis or anatomy-related diagnosis through pre-structured examination checklists. Coding of ICD-9/-10 as well as AO-classification and AIS (abbreviated injury scale). Implementation of scorings. Medical performance documentation through forms including pre-defined billing codes. Presentation of the documentation flow and its transfer into other contexts.
Discussion:
Pure text-based clinical results do not allow sufficient evalutation for quality assurance and medical performance documentation. However, a computer-based and immediate documentation in outpatients' departments should not mean a significantly increased workload for physicians.
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