The influence of digital clinical documentation on patient safety in a university hospital

Abstract

The ultimate goal of digitalization in healthcare is optimized, safe and efficient patient care. To achieve this goal, the E-Health Act stipulates that every patient receives a digital data pool with all health-relevant information that all healthcare providers can access. In this way, competencies are to be combined and costs and time expenditure can be reduced. The basis for this project is a digital documentation of all medical facilities. The Department of Oral and Maxillofacial Surgery at Göttingen University Hospital has been working with a digital patient file in the Meona software since June 2020. In this study, 100 analog and 100 digital patient files were analyzed to clarify whether digital documentation can contribute to greater patient safety. Using common statistical mean and group comparisons, data quality and quantity of both sample groups were compared.The analysis revealed superior quality of the digital documentation compared to the paperfiles. The better overview, traceability and readability that result of digitally documented clinical data offer great advantages in the area of patient and employee safety. When it comes to medication, the digital file is also superior to the analog file thanks to e.g. its precise orders and color markings. The digital signature and perfect readability also offer advantages in terms of communication as well as legal protection. Digital documentation therefore represents an elemental part on the way to safe and optimized patient care.

Keywords

• documentation
• patient safety
• oral and maxillofacial surgery
• digitalization