SYSTEMATIC PLANNING OF CLINICAL DOCUMENTATION

All information obtained from a patient in the course of medical care is a potential part of clinical documentation. The documentation usual ly serves a number of different purposes. The task of a documentation system is to fulfil these purposes in a methodically correct manner an d as economically as possible. This requires that the properties of th e documentation system be planned systematically with a view to the go als pursued. To support systematic planning, a ''documentation protoco l'' is proposed analogous to the ''study protocol'' used for controlle d clinical trials. The individual sections of the proposed documentati on protocol are described and the design options which exist in the co rresponding planning phases are pointed out. Experience gained by the application of the documentation protocol is discussed.