[Standardized computer-based documentation system for diagnoses and medical performance in orthopedics and traumatology. Development and initial application].
BACKGROUND
Increasing demands on quality assurance und medical performance documentation require an immediate and evaluable documentation in the outpatients' department. Presentation of a new computer-based diagnostic system for reporting and medical performance documentation.


METHODS
Development and initial application of the system in three big orthopedical or traumatological hospitals. Judgements about the feasibility of immediate documentation in outpatients' departments.


RESULTS
Presentation of an outpatients' departments diagnostic system with textblock-oriented anamnesis or anatomy-related diagnosis through pre-structured examination checklists. Coding of ICD-9/-10 as well as AO-classification and AIS (abbreviated injury scale). Implementation of scorings. Medical performance documentation through forms including pre-defined billing codes. Presentation of the documentation flow and its transfer into other contexts.


CONCLUSIONS
Pure text-based clinical results do not allow sufficient evaluation for quality assurance and medical performance documentation. However, a computer-based and immediate documentation in outpatients' departments should not mean a significantly increased workload for physicians.
D004282:Documentation; D005392:First Aid; D006801:Humans; D016347:Medical Records Systems, Computerized; D009985:Orthopedics; D010044:Outpatient Clinics, Hospital; D011785:Quality Assurance, Health Care; D012720:Severity of Illness Index; D014194:Traumatology; D014947:Wounds and Injuries / Q000145:classification