Abstract
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 overruling all medical documentary needs. Due to unchanged personnel resources in hospitals and due to a lack of comfortable tools ...
Abstract
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 overruling 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.
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