Methods Inf Med 1996; 35(01): 25-34
DOI: 10.1055/s-0038-1634638
Original Article
Schattauer GmbH

Systematic Planning of Clinical Documentation

F. Leiner
1  University of Goettingen, Department of Medical Informatics, Goettingen
,
R. Haux
2  University of Heidelberg, Institute of Medical Biometry and Informatics, Department of Medical Informatics, Heidelberg, Germany
› Author Affiliations
Further Information

Publication History

Publication Date:
14 February 2018 (online)

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.