[Documentation in the hospital--methods and types of system (author's transl)].
Types of system and methods of documentation in clinic or hospital must be directed towards the object of the documentation: indexing or search documentation, informative or data documentation. Furthermore, a careful selection of the facts to be documented must be established, because a "complete clinical documentation" is unrealistic. Subtle knowledge of the methods of translation of medical facts into code numbers (coding techniques) is inevitable. Examples show how a very comprehensive data collection can be achieved in a short time from the documentation of only a few facts. Currently acquired data must be fed immediately for evaluation. The fact is criticized that some research promoters, when giving financial assistance for the installation of a data bank, shy away from providing the means for computer evaluation. In this way, useless "electronic data cemeteries" are produced. Consequently the demand, not only for the installation of data banks, but also to provide for their evaluation is deduced.
D003936:Diagnosis, Computer-Assisted; D006747:Hospital Communication Systems; D006801:Humans; D008499:Medical Records; D008545:Melanoma; D008938:Mitosis; D011110:Polymorphism, Genetic; D011676:Punched-Card Systems; D012871:Skin Diseases
Dokumentation in der Klinik. Methoden und Organisationsformen