Bülzebruck H, Dienemann H, Vogt-Moykopf I
Thoraxklinik Heidelberg-Rohrbach, Heidelberg.
Langenbecks Arch Chir Suppl Kongressbd. 1997;114:240-5.
In various aspects, it is important to document medical procedures performed in surgical management. These records have become even more relevant because, in realizing the German health structure law, new forms of remuneration have been established, which are correlated with defined services. This means that data from medical documentation records today "rule" on financial compensation and, consequently, on the total economy of a hospital. Data are to be gathered considering multiple clinical and administrative requests; they have to register all pre-, intra- and postoperative details in their complex correlations; and, they are subject to strictly limited periods of compulsory availability. To meet these demands, data can only be recorded and evaluated by adequate computerized information systems. Starting out from a general data profile in response to questions from inside and outside of the hospitals, general criteria will be presented on what is to be recorded and how data are to be structured by surgery information systems. We will also refer to the interfaces required with information systems of other clinical departments that are part of the overall hospital information system. On this basis, guidelines are set up on how to plan, select, introduce and efficiently run these systems.
在各个方面，记录手术管理中实施的医疗程序非常重要。这些记录变得更加重要，因为在实施德国健康结构法时，已经建立了新的薪酬形式，这些薪酬形式与特定服务相关联。这意味着如今来自医疗文档记录的数据“决定”了经济补偿，进而影响医院的整体经济状况。收集数据时要考虑多种临床和行政要求；必须记录所有术前、术中和术后细节及其复杂的关联；并且，数据的强制可用期限受到严格限制。为满足这些要求，数据只能通过适当的计算机化信息系统进行记录和评估。从响应医院内部和外部问题的一般数据概况出发，将提出关于手术信息系统应记录哪些内容以及如何构建数据的一般标准。我们还将提及与作为医院整体信息系统一部分的其他临床科室信息系统所需的接口。在此基础上，制定了关于如何规划、选择、引入和高效运行这些系统的指南。
