[Electronic documentation of injuries of the hand with a semantic network: effective and efficient methods for the documentation of clinical and administrative processes].
BACKGROUND
An efficient medical documentation is mandatory for a trauma-oriented department in the DRG environment. Besides the continuously increasing clinical/administrative demands, the additional documentation for quality assurance, clinical studies, and research requires additional efforts. Standard solutions are only partially effective. Especially in hand surgery there is a high demand for sophisticated clinical documentation, represented by a wide variety of classifications in diagnosis and therapy. The standard documentation tools lack accuracy. The development of a software tool that defines administrative/business processes and simultaneously generates clinical and administrative information was the goal of this project.


RESULTS
With a standard medical terminology, an innovative semantic network, and a completely new graphical user interface, it was possible to develop and introduce a software program specifically adjusted for hand surgery. This program facilitated for the first time a single-stage acquisition of clinically relevant scientific data and the simultaneous generation of DRG, quality assurance, and administrative data relevant for the hospital's revenues.


CONCLUSIONS
The newly developed software tool is a step forward into a new dimension of medical software, obviating the need for multi/documentation and significantly improving the quality of clinically relevant medical data.
Pelzer
M
M
Klinik für Hand-, Plastische- und Rekonstruktive Chirurgie, BG-Unfallklinik Ludwigshafen, Klinik für Plastische- und Handchirurgie der Universität Heidelberg, Ludwig-Guttmann-Strasse 13, 67071 Ludwigshafen. michael.pelzer@urz.uni-heidelberg.de
Diekmann
D
D
Ryssel
H
H
Germann
G
G
D003196:Computer Graphics; D003953:Diagnosis-Related Groups / Q000145:classification* / Q000458:organization & administration; D004282:Documentation / Q000379:methods*; D005858:Germany; D006230:Hand Injuries / Q000145:classification* / Q000175:diagnosis / Q000601:surgery; D006739:Hospital Administration; D006801:Humans; D020407:Internet; D016347:Medical Records Systems, Computerized / Q000458:organization & administration*; D011785:Quality Assurance, Health Care / Q000458:organization & administration*; D011885:Radius Fractures / Q000145:classification / Q000175:diagnosis / Q000601:surgery; D021361:Scaphoid Bone / Q000293:injuries / Q000473:pathology / Q000601:surgery; D012984:Software; D009626:Terminology as Topic; D017749:Total Quality Management / Q000458:organization & administration; D014584:User-Computer Interface