Analyse und Sicherung der ordnungsgemäßen ärztlichen Dokumentation

Autor:	Müller Rt
Rok vydání:	2008
Předmět:	medicine.medical_specialty Assurance qualite Behaviour pattern business.industry Documentation system medicine.disease Surgery Medical documents Documentation Clinical investigation Medicine Orthopedics and Sports Medicine Medical emergency business
Zdroj:	Zeitschrift für Orthopädie und ihre Grenzgebiete. 130:367-370
ISSN:	1438-941X 0044-3220
Popis:	A written report on the findings of the examination forms the basis for the further procedure in the treatment of a patient--not merely in the area of orthopaedics. The examination findings should, therefore, be legible, readily understandable and complete. On the basis of 600 individual findings established at admission in the case of inpatients with diseases of the spine and hip, stemming from a total of three hospitals, the behaviour pattern of the individual examiner is analysed along with deficiencies in documentation. For a number of significant deficits, differences in the particular emphasis applied by individual physicians during the examination, the fact that the time available for such examinations is usually limited, and the lack of documentation system, are probably responsible.
Databáze:	OpenAIRE
Externí odkaz:	https://explore.openaire.eu/search/publication?articleId=doi_________::a6bc2e91cc7567886853678548a4a876 https://doi.org/10.1055/s-2008-1039636 Zobrazit plný text záznamu