Einführung eines klinischen Arbeitsplatzsystems am Beispiel der Klinik für Unfallchirurgie, Orthopädie und plastische Chirurgie

Ein retrospektiver Vergleich von analogen und digitalen Patientenkurven hinsichtlich der Datenqualität sowie den rechtlichen Anforderungen an die Dokumentation

by Marie-Therese Tolle
Doctoral thesis
Date of Examination:2023-08-08
Date of issue:2023-08-07
Advisor:PD Dr. Claus Wolff-Menzler
Referee:PD Dr. Claus Wolff-Menzler
Referee:Prof. Dr. Wolfgang Lehmann
Persistent Address: http://dx.doi.org/10.53846/goediss-9961

 

 

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Abstract

English

The main goal of the study is to analyze the legal requirements of the documentation of medical files in Germany. The methodology was firstly based on a literature review. Secondly, an analysis concerning the completeness of digital, as well as analogous documented medical files was performed. The research was based on the analysis of 100 protocols, documenting the three most common surgical procedures at the university Hospital of Trauma, Orthopedics and Plastic surgery, each either documented digitally or analogously. The evaluation of the data followed an initially descriptive method. Results show a greater completeness of digitally documented files. Especially signatures appear to be more present on the digital format.
Keywords: legal requirements; documentation; digitalization; Hospital of Trauma, Orthopedics and Plastic surgery
Schlagwörter: rechtliche Anforderungen; Digitalisierung; Dokumentation; Klinik für Unfallchirurgie, Orthopädie und plastische Chirurgie; Krankenhauszukunftsgesetz