Structured Reporting of Medical Findings: Evaluation of a System in Gastroenterology

K. Kuhn; W. Gaus; J. G. Wechsler; P. Janowitz; J. Tudyka; W. Kratzer; W. Swobodnik; H. Ditschuneit

doi:10.1055/s-0038-1634885

Methods of Information in Medicine, Inhaltsverzeichnis

Methods Inf Med 1992; 31(04): 268-274
DOI: 10.1055/s-0038-1634885

Original Article

Schattauer GmbH

Structured Reporting of Medical Findings: Evaluation of a System in Gastroenterology

K. Kuhn

¹Dept. Internal Medicine II, University of Ulm, Germany

,

W. Gaus

²Dept. Clinical Documentation, University of Ulm, Germany

,

J. G. Wechsler

¹Dept. Internal Medicine II, University of Ulm, Germany

,

P. Janowitz

¹Dept. Internal Medicine II, University of Ulm, Germany

,

J. Tudyka

¹Dept. Internal Medicine II, University of Ulm, Germany

,

W. Kratzer

¹Dept. Internal Medicine II, University of Ulm, Germany

,

W. Swobodnik

³2nd Medical Clinic, Technical University of Munich, Germany

,

H. Ditschuneit

¹Dept. Internal Medicine II, University of Ulm, Germany

› Institutsangaben

Abstract

Abstract:

A system using structured reporting of findings was developed for the preparation of medical reports and for clinical documentation purposes in upper abdominal sonography, and evaluated in the course of routine use. The evaluation focussed on the following parameters: completeness and correctness of the entered data, the proportion of free text, the validity and objectivity of the documentation, user acceptance, and time required. The completeness in the case of two clinically relevant parameters could be compared with an already existing database containing freely dictated reports. The results confirmed the hypothesis that, for the description of results of a technical examination, structured data reporting is a viable alternative to free-text dictation. For the application evaluated, there is even evidence of the superiority of a structured approach. The system can be put to use in related areas of application.

Key-Words

Documentation System - Evaluation - Structured Data

Volltext

Referenzen

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