Effenberger H, Mechtler R, Jerosch J, Munzinger U, Winter T
Orthopädische Abteilung, Landeskrankenanstalten Salzburg.
Z Orthop Ihre Grenzgeb. 1998 Mar-Apr;136(2):97-109. doi: 10.1055/s-2008-1051291.
To evaluate the level of documentation as an instrument of ongoing quality management in arthroplasty, a questionnaire was created on this subject, which concentrated on structural and process indicators.
A total of 908 questionnaires was sent to orthopedic and trauma departments in Austria, Germany and Switzerland and were evaluated anonymously.
The quota of return was 54% in Switzerland, 47% in Austria and 25% in Germany. The waiting period for an arthroplasty is much less in Switzerland and in Germany than in Austria. Only 40% of patients receive forms for informed consent. Documentation is seldomly standardized thus making comparison virtually impossible. Surgical planning is usually done with templates in Germany and Austria, in Switzerland with drawings. Prosthesis passports are predominately used by orthopedic departments. The data regarding complication rates and infections are not analyzed at regular intervals (max. 30%) and corrective measures are rarely implemented.
Documentation is the basic instrument of quality management and requires completeness (totality) and plausibility of the datas. It is of great importance that evaluated data are analyzed and consequences are taken. The primary aim of quality assurance is to identify problems that adversely affect quality in order to develop and implement process sequences for the improvement of patient care and management.
为了评估作为关节置换术中持续质量管理工具的文档记录水平，针对该主题设计了一份问卷，重点关注结构和过程指标。
总共向奥地利、德国和瑞士的骨科与创伤科发送了908份问卷，并进行匿名评估。
瑞士的问卷回收率为54%，奥地利为47%，德国为25%。瑞士和德国的关节置换等待期比奥地利短得多。只有40%的患者收到知情同意书。文档记录很少标准化，因此几乎无法进行比较。德国和奥地利的手术规划通常使用模板，瑞士则使用图纸。骨科部门主要使用假体护照。并发症发生率和感染数据并非定期分析（最高30%），很少采取纠正措施。
文档记录是质量管理的基本工具，要求数据完整（全面）且合理。对评估数据进行分析并采取相应措施非常重要。质量保证的主要目标是识别对质量产生不利影响的问题，以便制定和实施改进患者护理与管理的流程。
