[Standardized computer-based documentation system for diagnoses and medical performance in orthopedics and traumatology. Development and initial application]. / Standardisiertes EDV-gestütztes Befundungs- und Leistungsdokumentationssystem für die Orthopädie bzw. Traumatologie. Entwicklung und erste Anwendung.

INTRODUCTION: Increasing demands on quality assurance und medical performance documentation require an immediate 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 orthopedical or traumatological hospitals. Judgements 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 evaluation 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.

Development of a standardised computer-based documentation system for diagnoses and medical performance in orthopeadics/traumatology.

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.