[Rational EDP-basic documentation in the surgical clinic].
The establishment of a clinical basis documentation has approved because of the co-operation with the service-computer-centre of the clinical administration by linking the administrative and clinical data of the patients. The most essential data like diagnosis, operation, complication, operating surgeon as well as the eventual case of death will be registered in a protocol by the ward physician. These data will be registered by a documentary assistant according to the international keys. The evaluation of the data is done by a SPSS-program. The present results demonstrate that this kind of computer assisted clinical documentation has been successful.
D000293:Adolescent; D000328:Adult; D000368:Aged; D002648:Child; D002675:Child, Preschool; D003201:Computers; D003933:Diagnosis; D005260:Female; D005860:Germany, West; D006748:Hospital Departments / Q000458:organization & administration*; D006801:Humans; D007223:Infant; D008297:Male; D008499:Medical Records; D008875:Middle Aged; D011183:Postoperative Complications; D013503:Surgery Department, Hospital / Q000458:organization & administration*; D013514:Surgical Procedures, Operative
Rationelle EDV-Basisdokumentation in der Chirurgischen Klinik.