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Deimel D, Messer E, Thielemann HG, et al. Standardisiertes EDV-gestütztes Befundungs- und Leistungsdokumentationssystem für die Orthopädie bzw. Traumatologie. Development of a standardised computer-based documentation system for diagnoses and medical performance in orthopeadics/traumatology. Orthopade. 1999;28(3):285-291doi: 10.1007/PL00003609.
Deimel, D., Messer, E., Thielemann, H. G., & Picha, G. (1999). Standardisiertes EDV-gestütztes Befundungs- und Leistungsdokumentationssystem für die Orthopädie bzw. Traumatologie. Development of a standardised computer-based documentation system for diagnoses and medical performance in orthopeadics/traumatology. Der Orthopade, 28(3), 285-291. https://doi.org/10.1007/PL00003609
Deimel, D, et al. "Standardisiertes EDV-gestütztes Befundungs- und Leistungsdokumentationssystem für die Orthopädie bzw. Traumatologie." Development of a standardised computer-based documentation system for diagnoses and medical performance in orthopeadics/traumatology. Der Orthopade vol. 28,3 (1999): 285-291. doi: https://doi.org/10.1007/PL00003609
Deimel D, Messer E, Thielemann HG, Picha G. Standardisiertes EDV-gestütztes Befundungs- und Leistungsdokumentationssystem für die Orthopädie bzw. Traumatologie. Development of a standardised computer-based documentation system for diagnoses and medical performance in orthopeadics/traumatology. Orthopade. 1999 Mar;28(3):285-291. doi: 10.1007/PL00003609. PMID: 28246947.
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Orthopade. 1999 Mar;28(3):285-291. doi: 10.1007/PL00003609.

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

Der Orthopade

D Deimel, E Messer, H-G Thielemann, G Picha

Affiliations

  1. Orthopädische Klinik, Universitätsklinikum Mannheim, Germany.
  2. Klinik für Unfallchirurgie, Klinikum Rosenheim, Germany.
  3. Klinik für Unfallchirurgie, Klinikum Villingen-Schwenningen, Germany.

PMID: 28246947 DOI: 10.1007/PL00003609

Abstract

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.

Keywords: Key words Quality assurance • Medical performance documentation • Computer-assisted coding • Diagnostics • Abbreviated injury scale

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