• K Homayounfar, J Spiller, F von Stillfried, and M Raible.
• Klinik für Unfall-, Hand- und Wiederherstellungschirurgie, Klinikum Kassel GmbH, Kassel, Deutschland.
• Unfallchirurg. 2007 Dec 1; 110 (12): 1076-81.

BackgroundDocumentation of the individual treatment course is essential from medical as well as economic and forensic aspects. With increasing hospital computerization the conventional hardcopy form of record keeping is seen to be associated with high outlays and restrictiveness.MethodsClinicians engaged consistently in the development of a personal digital assistant (PDA)-based electronic record system (Clinic Coach(c)), which maps the entire course of inpatient treatments. The system's effectiveness was reviewed by means of a standardized questionnaire and analysis of 8,595 data sets relating to PPR and wound findings.ResultsIn patients undergoing surgery wound findings and PPR were documented in 83.6% and in 94.3% respectively. The ClinicCoach(c) System was rated more effective than paper-based documentation by 78.4% of the testing healthcare workers.ConclusionThe combination of PDAs and ClinicCoach(c) is a reliable and to clinical routine well adapted system that allows digital documentation at the bedside.

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