German Emergency Department medical record

The section Emergency Department medical record of the German Interdisciplinary Association of Critical Care and Emergency Medicine (DIVI) has set a goal to create a uniform clinical documentation for emergency department patients, which could be applicable in every discipline. The similar documentation to control the commitment of the emergency doctors (DIVI Notarzteinsatzprotokoll) is already in preclinical general exploitation.

The usage of the uniform ED record within a hospital improves the information transfer between different organizations. Also, the unification of the documentation creates the number of possibilities for cross-clinic evaluations, health-services research and quality improvement in the form of benchmarking.

The ED record is the basis for the AKTIN Project “National Emergency Department Register: Improvement of Health Services Research in Acute Medicine in Germany”. This ED record is the basis for the construction of the register. It represents the uniform documentation standard currently applied in several project-participating clinics. The aim of the working group is to develop an interdisciplinary data set for the early clinical documentation of emergency patients, which is comparable to the MIND2 preclinical DIVI ambulance record. The Section was founded in the autumn 2007 and has been working on that goal.

The user-friendly digital forms will help to reduce the redundant documentation, improve the accounting procedures in outpatient as well as in the inpatient area. The significant indicator of the interdisciplinarity is the cooperation of professional societies, who are involved in the emergency treatment of patients. Thus, the section is in close contact with a number of German medical societies: German Society for Surgery (DGCH), German Society for Traumatology (DGU), German Society for Anesthesiology and Intensive Care Medicine (DGAI), German Society for Neurology (DGN), the German Society for Internal Intensive Care and Emergency Medicine (DGIIN), the German Society for Interdisciplinary Emergency Department (DGINA).

The ED record is currently available in the Version V2015.1. If you would like to use it, please contact Dr. Dominik Brammen via E-mail. We are pleased to provide you with the new Version of the record.

Sprecher der Sektion:

Prof. Dr. med. Felix Walcher, MME
Direktor der Klinik für Unfallchirurgie
Universitätsklinikum Magdeburg A.ö.R.
Leipziger Str. 44
39120 Magdeburg

Stellvertreter:

Dr. med. Martin Kulla

Schriftführer:

Dr. med. Dominik Brammen

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