Schaub W, Thoma W, Volke M
Orthopädische Universitäts- und Poliklinik, Frankfurt/Main.
Z Orthop Ihre Grenzgeb. 1992 Sep-Oct;130(5):364-6. doi: 10.1055/s-2008-1039635.
The procedures of documentation of diagnostic findings are well established--but different in their graphical and structural appearance of patients histories. Out of multiple findings a retrieval with valid informations is very clumsy. In order to increase quality a complete and reliable registration of clinical data base is necessary. For this purpose the use of electronic media is profitable if the requirements of the data-base are well defined. A nationwide agreement on one key-system--including the transformation of textual structures--is proposed. Only this way leads to comparable results in therapeutic procedures.
诊断结果的记录程序已经确立，但患者病史的图形和结构呈现方式各不相同。在众多发现中检索有效信息非常笨拙。为了提高质量，有必要对临床数据库进行完整且可靠的登记。为此，如果数据库的要求明确，使用电子媒体是有益的。建议在全国范围内就一个关键系统达成一致，包括文本结构的转换。只有这样才能在治疗程序中获得可比的结果。
