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
