[Electronic documentation of injuries of the hand with a semantic network: effective and efficient methods for the documentation of clinical and administrative processes].

BACKGROUND: An efficient medical documentation is mandatory for a trauma-oriented department in the DRG environment. Besides the continuously increasing clinical/administrative demands, the additional documentation for quality assurance, clinical studies, and research requires additional efforts. Standard solutions are only partially effective. Especially in hand surgery there is a high demand for sophisticated clinical documentation, represented by a wide variety of classifications in diagnosis and therapy. The standard documentation tools lack accuracy. The development of a software tool that defines administrative/business processes and simultaneously generates clinical and administrative information was the goal of this project.

METHODS AND RESULTS: With a standard medical terminology, an innovative semantic network, and a completely new graphical user interface, it was possible to develop and introduce a software program specifically adjusted for hand surgery. This program facilitated for the first time a single-stage acquisition of clinically relevant scientific data and the simultaneous generation of DRG, quality assurance, and administrative data relevant for the hospital's revenues.

CONCLUSIONS: The newly developed software tool is a step forward into a new dimension of medical software, obviating the need for multi/documentation and significantly improving the quality of clinically relevant medical data.