[CleftData. Program for minimal documentation of lip-jaw-palate clefts].
BACKGROUND
The aim of the German Study Group on Cleft Lip and Palate-Craniofacial Deformities is to develop a precise system for documentation of cleft lip and palate patients which is suitable for use in PC-databases.
In cooperation with the medical disciplines involved in the therapy such as otolaryngology, oral and maxillofacial surgery, orthodontics and speech therapy a system of documentation was developed with regard to the international classification of diseases (ICD) and the operating procedures system (OPS). Malformations are classified with the LAHS coding system. In addition to this concept of minimal documentation photographic images in standardized projections are stored. Furthermore, each operative procedure is documented by its date and the anatomic region of malformation treated without details of operative methods or descriptions of other procedures.
On behalf of the German Study Group on Cleft Lip and Palate a software to meet these purposes was developed called CleftData. Based on a relational Access database it is equipped with SQL connectivity enabling its use on all hard- and software-systems.
Nolting
P Th
PT
Abteilung für Mund-, Kiefer-, Gesichtschirurgie, Justus-Liebig-Universität, Klinikstrasse, 35385 Giessen. peer_nolting@hotmail.com
Koch
J
J
Werkmeister
R
R
Howaldt
H P
HP
D002971:Cleft Lip / Q000145:classification / Q000175:diagnosis / Q000601:surgery*; D002972:Cleft Palate / Q000145:classification / Q000175:diagnosis / Q000601:surgery*; D003625:Data Collection; D016208:Databases, Factual; D004282:Documentation / Q000379:methods*; D006801:Humans; D016347:Medical Records Systems, Computerized; D008838:Microcomputers; D010348:Patient Care Team; D012984:Software