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Bitte verwenden Sie diesen Link, wenn Sie dieses Dokument zitieren oder verlinken wollen: https://nbn-resolving.org/urn:nbn:de:gbv:9-000521-9

Mobile Klinikdokumentation - Vorgaben, Lösungsansätze und Ergebnisse einer randomisierten, kontrollierten Studie

  • Medizinische Dokumentation wird im Zeitalter von DRG und Klinikvernetzung einen grundlegenden Wandel erfahren. Sie soll neben der Verlaufsdokumentation der medizinisch relevanten Befunde und rechtlichen Rahmenbedingungen den Anforderungen der Leistungsvergütung, dem wirtschaftlichen Wettbewerb im Rahmen von Mindestmengen und wissenschaftlichen Fragestellungen gerecht werden. Unterschiedlich professionalisierte Gruppen im Gesundheitssystem haben differenzierte Vorgaben und Vorstellungen von einer transparenten medizinischen Dokumentation. Für Ärztinnen und Ärzte steht die Zeitknappheit im Vordergrund. Die Diskrepanz zwischen Vollständigkeit und Korrektheit der täglichen Visitendokumentation und ihre abschließende Zusammenfassung in einer kumulativen Epikrise könnte durch die Einführung mobiler Computersysteme und spezifischer Softwarelösungen überwunden werden.
  • In a diagnosis-related groups (DRG) environment, and with the emerging trend towards hospital networking, the demands to medical documentation are increasing rapidly. Apart from purely depicting relevant clinical findings, medical documentation must meet legal requirements, reimbursement regulations, the capability of business competition, and scientific questions at the same time. Different players in the health care sector share different opinions about a “perfect” documentation system. For doctors, time constraints come to the fore, and the huge gap between completeness (i.e., sensitivity) and correctness (i.e., specificity) of diagnoses listed in the discharge note may be improved by the introduction of mobile computing. In a randomized controlled trial, the coding software Meditrace®, installed on a hand-held-Psion-PDA was compared to routine manual, paper-based documentation on a surgical ward. The primary trial endpoint was the number of ICD-10-codes identified and entered on daily rounds. Secondary outcomes comprised three different dimensions of coding quality, as assessed by expert raters on a five-point-scale, as well as the doctors’ ratings of satisfaction and practicability with either modality Eighty patients were randomized, 78 of whom (47 men, 31 women, mean age 48.2 ± 17.4 years) were eligible for the final analysis. In the experimental Meditrace® group, there were a total of 411 (median 9, interquartile range [IQR] 6 – 14) diagnoses, compared to 157 (median 4, IQR 3 – 5) diagnoses in the paper-based control group (Mann-Whitney-test p<0.0001). There were 48 and 7 false-positive diagnoses in the experimental and the control group, respectively (risk difference 7.2%, 95% confidence interval 2.0 – 11.4%, p=0.009). After correction for “over-coding”, the advantage of the hand-held computer over manual documentation remained statistically significant. All three dimensions of coding quality, as well as satisfaction and practicability ratings tended to be better in the hand-held computer group, although this difference did not reach statistical significance. The introduction of an electronic mobile documentation system may improve both the quantity and quality of medical coding compared to established paper-based methods.

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Metadaten
Author: Peter Heumann
URN:urn:nbn:de:gbv:9-000521-9
Title Additional (English):Mobile hospital documentation with hand-held computers and specific coding software. Prerequisites, probable solutions, and results of a randomized controlled trial
Advisor:Prof. Dr. Dr. h.c. Axel Ekkernkamp
Document Type:Doctoral Thesis
Language:German
Date of Publication (online):2008/10/07
Granting Institution:Ernst-Moritz-Arndt-Universität, Medizinische Fakultät (bis 2010)
Date of final exam:2008/07/23
Release Date:2008/10/07
Tag:PDA radomisiert kontrolliert
hand-held controlled randomized
GND Keyword:Dokumentation, Krankenhaus, Studie
Faculties:Universitätsmedizin / Klinik und Poliklinik für Chirurgie Abt. für Unfall- und Wiederherstellungschirurgie
DDC class:600 Technik, Medizin, angewandte Wissenschaften / 610 Medizin und Gesundheit