Klinische Dokumentation in der Geburtshilfe und Erfassung relevanter Daten im Hinblick auf das Strukturreformgesetz

Abstract

This study was conducted on the spread and usage of computer-aided software programme (GDS) in 72 obstetric departments. Standardised questionnaires were sent to universities and hospitals to ask for information on registered perinatal data. The record with the hand-written delivery book cannot record all data needed for quality protection as the PC is able to list. 89% of the obstetricians evaluate their clinical data regularly by statistical survey and classification. By analysing the general trend they can critically assess their actual obstetrical management. The PC is established in 83%, functions without technical problems in 92% and is optimal in the sequence of operation in 57% of all departments questioned. Overtime hours for the staff could be reduced in 11%, if a computer was used, and in 13% the nurses could take more care of mother and child because of less official red tape. Independent of the size of the department and the data processing knowledge of the staff, the software programme runs efficiently. The comprehensive basis data documentation with all perinatal and neonatal data is used to its full extent in 100% of the cases and documents the clinical effectivity. With regard to the standardised hospital quality control process by the modified requirements in the public health legislation, the directors of the hospital departments are able to assess the quality control and show economic independence.