[Electronic data processing-compatible documentation in neurology--developmental stage of neurologic findings for a specialty-specific scientific evaluation system and print-out of a computer assisted epicrisis].
A computer compatible neurological examination record has been drawn up for a neurological documentation called "ADOK Neurologie" as part of a scheme for the basic registration of patient-related information from all patients receiving ward treatment at the Medical Academy Dresden and the County Neurological and Psychiatric Hospital Arnsdorf. The examination questionnaire consists of dichotomous questions and permits up to 1,525 separate items of neurological information per patient to be stored and processed. The information permits purposeful scientific analysis and computer print-out of the epicrisis. The article reports on the structure of the questionnaire, the prospects and limits of the method and experience gained during many years of practical use.
D003201:Computers; D005859:Germany, East; D006801:Humans; D008499:Medical Records; D008501:Medical Records, Problem-Oriented; D009422:Nervous System Diseases / Q000175:diagnosis / Q000628:therapy*; D009460:Neurologic Examination / Q000295:instrumentation; D012984:Software
EDV-gerechte Dokumentation in der Neurologie--Ausbaustufe neurologischer Befunde für ein fachspezifisches wissenschaftliches Auswertungssystem und Ausdruck einer rechnergestützten Epikrise.