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Systematic planning of clinical documentation

F Leiner1, R Haux

  • 1Department of Medical Informatics, University of Goettingen, Germany.

Methods of Information in Medicine
|March 1, 1996
PubMed
Summary
This summary is machine-generated.

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A structured documentation protocol, similar to study protocols, aids in systematically planning clinical documentation systems. This approach ensures documentation meets multiple purposes effectively and economically.

Area of Science:

  • Medical Informatics
  • Health Information Management

Background:

  • Clinical documentation is crucial for patient care and serves multiple purposes.
  • Current documentation systems require systematic planning to be effective and economical.

Purpose of the Study:

  • To propose a structured "documentation protocol" to guide the systematic planning of clinical documentation systems.
  • To outline the sections of the proposed protocol and available design options.

Main Methods:

  • The study proposes a documentation protocol analogous to study protocols used in clinical trials.
  • It describes the protocol's sections and planning phase design options.

Main Results:

  • The proposed documentation protocol provides a framework for systematic planning.

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  • Application experience with the protocol is discussed, highlighting its utility.

    • Conclusions:

    • Systematic planning using a documentation protocol enhances the efficiency and effectiveness of clinical documentation systems.
    • The protocol supports achieving methodical correctness and economic feasibility in documentation.