Systematic planning of clinical documentation.

@article{Leiner1996SystematicPO,
  title={Systematic planning of clinical documentation.},
  author={Florian Leiner and Reinhold Haux},
  journal={Methods of information in medicine},
  year={1996},
  volume={35 1},
  pages={25-34}
}
All information obtained from a patient in the course of medical care is a potential part of clinical documentation. The documentation usually serves a number of different purposes. The task of a documentation system is to fulfil these purposes in a methodically correct manner and as economically as possible. This requires that the properties of the documentation system be planned systematically with a view to the goals pursued. To support systematic planning, a "documentation protocol" is… CONTINUE READING
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