Prinzipien einer zielgerichteten Klinischen Dokumentation

Author(s): Haux, R.

Journal/Book: (Manuskript) (1994 erschienen in Informationstechnik und technische Informatik)). 1994;

Abstract: All patient-related information originating from the process of medical care is subject to clinical documentation. The principal responsibility of clinical documentations lies in the support of patient care, of clinical research, of hospital reporting, of quality assurance, and of clinical training. Moreover, they are essential in satisfying legal recording and reporting requirements. The paper summarizes the selected methodical concepts of patient-oriented documentation, multiple usability of data, standardized documentation, controlled medical vocabularies, and clinical registries. The issue of quality of clinical data is briefly discussed. Goal-oriented planning of clinical documentation systems is considered essential. The structure of a, documentation protocol' is presented.

Zurück | Weiter