Problems with Current Dental Documentation in Germany

Background: dental documentation is essential for the representation and communication of dental information amongst researchers and practitioners. Dental documentation has to provide the respective means for (a) the representation of the patient status’ and (b) the possible actions. Methods: the consistency of German definitions currently used for dental findings is evaluated by projecting well known examples onto problem axes like “existence of a structure” and “condition of a structure”. Results: it can be shown that current German dental terminology does not support an unambiguous documentation for any situation in dental practice. In some cases, Multiple aspects are merged in several finding statements and make a stringent derivation of the treatment planning difficult. Conclusions: dental documentation in Germany can in some aspects be improved with respect to (a) precision, (b) expressiveness, (c) simplicity and (d) reproducibility. The main axes of dental documentation are enumerated in preparation of a future top-down approach. Clinical Implications: an optimised finding scheme can enhance the communication amongst researchers and practitioners and thus is supposed to improve the treatment quality in the long run

Preparations for the Evaluation of a Speech Recognition System in Neonatology (U2)

Background: before using a speech recognition system for the neonatal documentation, the underlying neonatal information has to be specified and structured. Up to now, the pre-structuring the first comprehensive examination of newborn (U2) and the respective data set entries has not been described in literature, yet. The common booklet for the documentation of the German U2 does not contain all examinations required nor does it show the choice of all respective finding statements. Objectives: to set up a documentation standard for the U2 distinguishing the most important diseases/disorders at a limited level of detailing. Methods: the finding scheme of the U2 has been specified based on the German national recommendation for the U2. Here, the U2 is the first exhaustive examination of the newborn. Due to a lack of detailed descriptions, the U2 has been formalized and arranged in cooperation with experienced medical experts, which carry out the U2 in daily routine. Results: if all possible finding statements are presented in a hierarchical structure, – even with a small font size – it would cover more than 20 pages. Hence, a more condensed structure has been set up for presentation. If the general practitioner (GP) is to see (a) the finding statements necessary but (b) no more, additional rules can be set up for the masking of finding statements excluded by the results of the prior investigation. Conclusions: the proposed structure for neonatal documentation serves as a basis for statistical analysis. On its basis, investigation can be carried out about (a) problems during the individual examination, (b) problem with the documentation and (c) the benefits of automated speech recognition systems

Minimalist knowledge representation of primary care diseases in the medrapid.info knowledge base

Background Communication media commonly used in medicine today no longer meet the needs brought on by the present knowledge explosion. The Heidelberg medrapid project has been developed to quickly communicate high-quality clinical knowledge to physicians. Methods In this paper, medrapid is introduced as an online clinical knowledge resource, and the methods used by the 'knowledge entry' function for the minimalist representation of clinical knowledge in the knowledge base are discussed. Results On average, fewer than 1.4 problems per disease arose during the input of the formal representation of clinical knowledge using the 'knowledge entry' function. However, representation of disease time processes, descriptions, warnings and graphics with the 'knowledge entry' function remains problematic. Conclusions The 'knowledge entry' function allows fast formal representation of clinical knowledge (<14 minutes per disease) and testing using the integrated quality management system. In the near future, new measures must be found to improve the problematic representation of disease time processes, descriptions, warnings and graphics to formally represent clinical knowledge using the medrapid 'knowledge entry' function

MEDRAPID.INFO - Die klinische Wissensbank für Praxis, Forschung und Lehre

Mit medrapid.info wurde ein System zur raschen und präzisen Kommunikation von klinischem Wissen entwickelt. Der Zugriff auf das medrapid-Wissen ist kostenlos und ohne Anmeldung im Internet möglich. medrapid besitzt ein Autorensystem zur formalen Repräsentation von Wissen über Krankheitsbilder und deren Wechselwirkung in der medrapid Wissensbank. Das integrierte Qualitätsmanagement unterstützt die Autoren-Community in der Abstimmung der Inhalte zwischen den medizinischen Fachgebieten und führt zur Entwicklung eines gemeinsamen kontrollierten Vokabulars. Bisher wurden über 5000 Krankheitsbilder im medrapid-System abgebildet, von denen 4400 bereits das Qualitätsmanagement durchlaufen haben. Es wird damit gerechnet, dass gegen Jahresende 98% der klinischen Anfragen beantwortet werden können