[Use of computer applications to support clinical processes. An electronic letter of discharge as resource for DRG-relevant coding].
Not long ago forensic aspects where the major driving force to complete and correct medical documentation. Diagnosis related groups becoming basic data for billing of hospital treatment in Germany now extremely extend the need for complex administrative documentation over-ruling all medical documentary needs. Due to unchanged personnel resources in hospitals and due to a lack of comfortable tools supporting these documentary needs medical personnel in most hospitals is confronted with an annoying effort to fulfill these needs. As a result innumerable hours of working time have to be shifted from patient focused to administrative work. This paper introduces a computer system based on a hospital-wide documentation concept and clinical workflow allowing to derive administrative data straight from medical documents so that redundant documentation and discrepancies between medical and administrative documentation can be avoided.
Reng
Carl-Michael
CM
Klinik und Poliklinik für Innere Medizin I, Klinikum der Universität, Regensburg. michael.reng@medicdat.de
Tege
Birgit
B
Reicherzer
Hans-Georg
HG
Nass
Gertrud
G
Schacherer
Doris
D
Boerner
Wolfgang
W
Schölmerich
Jürgen
J
D003199:Computer Systems; D003953:Diagnosis-Related Groups; D004282:Documentation; D034742:Electronic Mail; D005858:Germany; D006801:Humans; D008500:Medical Records Department, Hospital; D016347:Medical Records Systems, Computerized; D010351:Patient Discharge
Einsatz elektronischer Verfahren zur Okonomisierung von ArbeitsabläufenDer Arztbrief als Hilfsmittel zur DRG-gerechten Diagnosendokumentation.