title: [Requirements for a surgical documentation system and its realization].
abstract: Adequate documentation of all surgical procedures is now essential. High demands in terms of quality and quantity mean that computerized databases and evaluation procedures are required. In the Department of Abdominal and Transplantation Surgery within Hanover Medical School a standardized but individually adaptable documentation system has been greated using standard hardware and software. A hierarchical code system has been established for surgical procedures, and this also offers the options of automatic online coding and translation into the coding used in the International Classification of Procedures in Medicine. The advantages and limitations of this system are discussed.
authors.affiliation: Klinik für Abdominal- und Transplantationschirurgie, Medizinische Hochschule Hannover.
authors.forename: J
authors.initials: J
authors.lastname: Klempnauer
authors.forename: J
authors.initials: J
authors.lastname: Neumann
mesh_terms: D003628:Database Management Systems / Q000295:instrumentation; D004282:Documentation / Q000379:methods*; D005858:Germany; D006801:Humans; D008838:Microcomputers; D009862:Online Systems / Q000295:instrumentation*; D009870:Operating Room Information Systems; D012984:Software; D013514:Surgical Procedures, Operative / Q000145:classification; D014180:Transplantation / Q000145:classification
vernacular_title: Anforderungen an ein Operationsdokumentationssystem und deren Realisation.