The hospital should define the scope of documentation for quality-related services in procedural instructions.<\/p>\n\n\n\n
The aim is to regulate how organisation and patient-related information can be stored, forwarded and retrieved.<\/p>\n\n\n\n
The presentation of the information in forms, their recording, possibly also via EDP, their forwarding and archiving must be clarified. Storage must be secured for the specified period. It must be possible to access the medical records within a reasonable period of time. The completeness of the medical records must be verifiable.<\/p>\n\n\n\n
The need for documentation must be clarified for each medical procedure with regard to traceability of measures, reporting in the workflow or economic purposes.<\/p>\n\n\n\n
When documenting, care must be taken to ensure that the recorded data can be transmitted quickly and without loss of information. The documentation serves the flow of information and must not hinder it. The data should be collected and archived in such a way that it can be analysed at a later date, including for comparison with other service providers.<\/p>\n\n\n\n
The statutory and professional regulations (Social Security Code, Professional Code, Federal Collective Labour Agreement, agreements on outpatient surgery, Narcotics Ordinance, Pharmacy Ordinance, Infection Protection Act, X-ray and Radiation Protection Ordinance, etc.) must be complied with. The statutory retention periods must be fulfilled.<\/p>\n\n\n\n
Proof of compliance with environmental protection obligations should be provided.<\/p>\n\n\n\n
The QM system should be documented in a quality management manual with a quality assurance plan, procedural instructions, method descriptions (care standards, work instructions, treatment samples). The manual may contain further directories (inventory of equipment, organisation chart with function descriptions, procedure list, recognised rules, validation documents).<\/p>","protected":false},"excerpt":{"rendered":"
Das Krankenhaus soll in Verfahrensanweisungen den Umfang der Dokumentation f\u00fcr die qualit\u00e4tsbezogenen Leistungen bestimmen. Geregelt werden soll, wie organisations- und patientenbezogene Informationen fixiert, weitergeleitet und wiedergefunden werden k\u00f6nnen. Die Darstellung der Information in Formularen, deren Erfassung, evtl. auch \u00fcber EDV, deren Weiterleitung und Archivierung m\u00fcssen gekl\u00e4rt werden. Die Aufbewahrung muss f\u00fcr den festgelegten Zeitraum gesichert […]<\/p>\n","protected":false},"author":1,"featured_media":0,"parent":10710,"menu_order":1,"comment_status":"open","ping_status":"closed","template":"","doc_tag":[],"doc_badge":[],"class_list":["post-10711","docs","type-docs","status-publish","hentry","no-post-thumbnail"],"acf":[],"author_avatar":"https:\/\/secure.gravatar.com\/avatar\/c6b2616140d9fcd6a1c5d6d2ebbf43422308c9322c032ef03f88ec3235855dcf?s=96&d=mm&r=g","author_name":"admin","_links":{"self":[{"href":"https:\/\/gutehospitalpraxis.de\/en\/wp-json\/wp\/v2\/docs\/10711","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/gutehospitalpraxis.de\/en\/wp-json\/wp\/v2\/docs"}],"about":[{"href":"https:\/\/gutehospitalpraxis.de\/en\/wp-json\/wp\/v2\/types\/docs"}],"author":[{"embeddable":true,"href":"https:\/\/gutehospitalpraxis.de\/en\/wp-json\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/gutehospitalpraxis.de\/en\/wp-json\/wp\/v2\/comments?post=10711"}],"version-history":[{"count":0,"href":"https:\/\/gutehospitalpraxis.de\/en\/wp-json\/wp\/v2\/docs\/10711\/revisions"}],"up":[{"embeddable":true,"href":"https:\/\/gutehospitalpraxis.de\/en\/wp-json\/wp\/v2\/docs\/10710"}],"wp:attachment":[{"href":"https:\/\/gutehospitalpraxis.de\/en\/wp-json\/wp\/v2\/media?parent=10711"}],"wp:term":[{"taxonomy":"doc_tag","embeddable":true,"href":"https:\/\/gutehospitalpraxis.de\/en\/wp-json\/wp\/v2\/doc_tag?post=10711"},{"taxonomy":"doc_badge","embeddable":true,"href":"https:\/\/gutehospitalpraxis.de\/en\/wp-json\/wp\/v2\/doc_badge?post=10711"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}