[Recommendation for a systematic solution of documenting findings in obstetrical and gynecologic ultrasound diagnosis].
Ultrasonic findings in a women's clinic are very heterogeneous. In their totality they will be unmethodical very quick. Therefore we decided to organize four separate card indexes: 1. gynaecologic findings; 2. breast diagnostics; 3. supervision of pregnancy and look for fetal malformations; 4. single findings in pregnancy.--Each card index does not exceed 2000 to 3000 patients by appropriate actualization. A filing card for supervision of pregnancy and systemic detection of fetal malformations is created.
D001943:Breast Neoplasms / Q000175:diagnosis; D005314:Embryonic and Fetal Development; D005260:Female; D005831:Genital Diseases, Female / Q000175:diagnosis*; D005833:Genital Neoplasms, Female / Q000175:diagnosis; D005865:Gestational Age; D006801:Humans; D008501:Medical Records, Problem-Oriented; D011247:Pregnancy; D011248:Pregnancy Complications / Q000175:diagnosis*; D011296:Prenatal Diagnosis / Q000379:methods; D014463:Ultrasonography / Q000379:methods*
Vorschlag einer Systemlösung der Befunddokumentation für die geburtshilfliche und gynäkologische Ultraschalldiagnostik.