Systematic Planning of Clinical Documentation

Abstract

All information obtained from a patient in the course of medical care is a potential part of clinical documentation. The documentation usually serves a number of different purposes. The task of a documentation system is to fulfil these purposes in a methodically correct manner and as economically as possible. This requires that the properties of the documentation system be planned systematically with a view to the goals pursued. To support systematic planning, a “documentation protocol” is proposed analogous to the “study protocol” used for controlled clinical trials. The individual sections of the proposed documentation protocol are described and the design options which exist in the corresponding planning phases are pointed out. Experience gained by the application of the documentation protocol is discussed.

Keywords

Medical Informatics - Documentation - Medical Record Systems

• REFERENCES

• 1 Feinstein AR. Clinical Judgment. Huntington NY: Krieger; 1967
• 2 Weed LL. Medical Records, Medical Education, and Patient Care – The Problem-Oriented Record as a Basic Tool. Cleveland: Case Western Reserve University Press; 1970
• 3 Leiner F. Systematische Planung klinischer Dokumentationen. (Doctoral Thesis) University of Heidelberg; 1983
• 4 Haux R, Winter A. Medizinische Informatik im Krankenhaus. Quintessenzen in der Medizin 1993; 1: 507-23.
• 5 Koller S, Wagner G. Wesen, Technik und Ziele der Dokumentation in der Medizin. In: Koller S, Wagner G. eds Handbuch der medizinischen Dokumentation und Datenverarbeitung. Stuttgart – New York: Schattauer; 1975: 3-10.
• 6 Dick RS, Steen EB. eds The Computer-Based Patient Record – An Essential Technology for Health Care. Washington DC: National Academy Press; 1991
• 7 Koller S, Wagner G. Wesen, Technik und Ziele der Dokumentation in der Medizin. In: Koller S, Wagner G. eds Handbuch der medizinischen Dokumentation und Datenverarbeitung. Stuttgart: Schattauer; 1975: 3-10.
• 8 Selbmann HK. Qualitätssicherung in der ambulanten Versorgung – Sicht des Sachverständigenrats für die Konzertierte Aktion im Gesundheitswesen. Fortschritte der Medizin 1992; 110: 183-6.
• 9 Sear J, Rigby MJ. A Conceptual Approach to the Strategic Management of Quality through Exploitation of Operational Data. In: Lun KC, Degoulet P, Piemme TE, Rienhoff O. eds Proceedings of the 7th World Congress on Medical Informatics. Amsterdam: Noth Holland; 1992: 1530-3.
• 10 Feinstein AR. Scientific standards in epidemiologic studies of the menace of daily life. Science 1988; 242: 1257-63.
• 11 Levy AH, Lawrance DP. Data acquisition and the computer-based patient record. In: Ball MJ, Collen MF. eds Aspects of the Computer-based Patient Record. New York: Springer; 1992: 125-39.
• 12 Haux R. Knowledge-based decision support for diagnosis and therapy: on the multiple usability of patient data. Meth Inform Med 1989; 28: 69-77.
• 13 Bakker AR, Ehlers CT, Bryant JR, Hammond WE. eds Hospital information systems: scope – design – architecture. Proceedings of the IMIA Working Conference on Hospital Information Systems. Amsterdam: North Holland: 1993
• 14 Pocock SJ. Clinical Trials – A Practical Approach. Chichester: Wiley; 1983
• 15 Meinert CL. Clinical Trials – Design, Conduct, and Analysis. New York: Oxford University Press; 1986
• 16 Wichmann HE, Lehmacher W. Manual für die Planung und Durchführung epidemiologischer Studien. Schriftenreihe der GMDS, Heft 11 Stuttgart: Schattauer; 1991
• 17 Dorfman M, Thayer RH. eds Standards, Guidelines, and Examples on System and Software Requirements Engineering. IOS Alamitos CA: IEEE Computer Society Press; 1990
• 18 Mann G, Haux R. Database scheme design for clinical studies based on a semantic data model. Computational Statistics and Data Analysis 1993; 15: 81-108.
• 19 Griesser G. Data protection in hospital information systems: Definition and Overview. In: Orthner HF, Blum BI. eds Implementing Health Care Information Systems. New York: Springer; 1989: 222-53.
• 20 Pangalos GJ. Medical database security policies. Med Inform Med 1993; 32: 349-56.
• 21 Werner R, Haux R, Leiner F, Winter A. An integrated approach for mobile information processing in hospitals. In: Greenes RA, Peterson HE, Protti DJ. eds Proceedings of the 8th World Congress on Medical Informatics. Amsterdam: North-Holland: 1995: 395-9.
• 22 Zachariou Z, Schiller U, Leiner F, Roth H, Haux R. Das Heidelberger Modell-Wissenschaftliche Fandokumentation in der Kinderchirurgie. Zentralblatt fUr Kinderchirurgie 1994; 3: 63-9.
• 23 Leiner F, Haux R, Glueck E. Systematische Planung medizinische Basisdokumentationen im Krankenhaus. Informatik, Biometrie und Epidemiologie in Medizin und Biologie 1993; 24: 199-213.
• 24 Van der Lei J. Use and abuse of computer-stored medical records. Meth Inform Med 1991; 30: 79-80.