Systematic Planning of Clinical Documentations - Part I: The Documentation Protocol (Teil 1 und 2)
Abstract: All information obtained an a patient in the course of medical care is potential component part of the clinical documentation. The documentation normally serves a number of different purposes. The task of a documentation system is to fulfil these purposes in a methodically correct manner and in a way as economical as possible. This is, in the authors' opinion, only feasible if the properties of the documentation system are planned systematically with a view to the aims pursued. In order to support systematic planning, a 'documentation protocol' is proposed in analogy to the 'study protocol' used for controlled clinical trials. The sections of the documentation protocol are described in brief and an account is given of the experience gained up to now by its application.
Keyword(s): Medical Informatics