Klempnauer J, Neumann J
Klinik für Abdominal- und Transplantationschirurgie, Medizinische Hochschule Hannover.
Langenbecks Arch Chir. 1995;380(4):224-8. doi: 10.1007/BF00207911.
Adequate documentation of all surgical procedures is now essential. High demands in terms of quality and quantity mean that computerized databases and evaluation procedures are required. In the Department of Abdominal and Transplantation Surgery within Hanover Medical School a standardized but individually adaptable documentation system has been greated using standard hardware and software. A hierarchical code system has been established for surgical procedures, and this also offers the options of automatic online coding and translation into the coding used in the International Classification of Procedures in Medicine. The advantages and limitations of this system are discussed.
现在，对所有外科手术进行充分记录至关重要。在质量和数量方面的高要求意味着需要计算机化数据库和评估程序。在汉诺威医学院的腹部与移植外科，利用标准硬件和软件创建了一个标准化但可个性化调整的记录系统。已为外科手术建立了一个分级编码系统，该系统还提供自动在线编码以及转换为《国际医学手术操作分类》中所用编码的选项。本文讨论了该系统的优缺点。
