title: Planning and introduction of clinical documentation in an university hospital.
abstract: At the Innsbruck University Hospital the documentation planning for the new hospital information system started by designing the structure of free text documents. This paper analyzes the needs of the physicians to document and retrieve information on a patient's visits and history. Considerations for the realization of these needs are outlined. Based on our experiences the organizational constraints e.g. validation of clinical information are demonstrated and discussed.
authors.affiliation: University of Innsbruck, Department of Biostatistics and Documentation, Schöpfstr. 41/1, A-6020 Innsbruck, Austria.
authors.forename: V
authors.initials: V
authors.lastname: Callegari
authors.forename: K P
authors.initials: KP
authors.lastname: Pfeiffer
mesh_terms: D001317:Austria; D003625:Data Collection; D004282:Documentation / Q000379:methods*; D006301:Health Services Needs and Demand; D006751:Hospital Information Systems; D006785:Hospitals, University; D006801:Humans; D016347:Medical Records Systems, Computerized; D012985:Software Design