Guideline based structured documentation: the final goal?
Structured documentation of medical procedures facilitates information retrieval for research and therapy and may help to improve patient care. Most medical documents until today however consist mainly of unstructured narrative text. Here we present an application for endoscopy which is not only fully integrated into a comprehensive clinical information system, but which also supports various degrees of structuring examination reports. The application is used routinely in a German University hospital since summer 2000. We present the first unstructured version which permits storage of a free text report together with selected examination images. The next step added improved structure to the document using a catalogue of index terms. The practical advantages of selective patient retrieval are described. Today we use a version which supports fully structured, guideline based documentation of endoscopy reports in order to automatically generate essential classification codes and the narrative examination report All versions have advantages and disadvantages and we conclude that guideline based documentation may not be suitable for all endoscopy cases.
Department of Medical Informatics and Biomathematics, Domagkstr 9, 48149 Münster, Germany.
Thomas
T
Bürkle
Thomas
T
Ganslandt
Dirk
D
Tübergen
Josef
J
Menzel
Torsten
T
Kucharzik
Klaus
K
Neumann
Stefan
S
Schlüter
Marcel
M
Müller
Ursula
U
Veltmann
Hans-Ulrich
HU
Prokosch
D004282:Documentation / Q000379:methods* / Q000592:standards; D004724:Endoscopy; D005858:Germany; D017408:Guidelines as Topic; D006801:Humans; D016247:Information Storage and Retrieval; D016347:Medical Records Systems, Computerized; D011787:Quality of Health Care