Purpose of a Structured History

No Data Redundancy

Often, history information of medical and nursing care are available in an unstructured form. This is usually due to handwritten forms, house catalogs and the various professions involved in collecting anamnestic data. In particular, the sometimes duplicated interviews on medical history and the associated collection of e.g. risk factors lead to data redundancy.

No Heterogenous Data Collection

At the same time, the data cannot be used interprofessionally, because the different perspectives and priorities of the professions involved on patients affect data collection. This heterogeneous data collection prevents the use of these data in the context of scientific evaluations on the one hand and the further utilization for the electronically supported documentation on the other hand. Also, there are no linkages to other instruments directly related to the history data, such as scores, diagnostics, instruments for measuring effort, etc.

Structured and Unambiguously Coded Anamnesis Data

For this reason, we have developed the interdisciplinary, databased electronic anamnestic structure IDEA, which is based on the use of a standardized knowledge-based and literature-supported collection of history information and linked to various instruments. All health-related data can be collected in a structured manner. The collected data of the patient/resident can be retrieved and, if necessary, edited at any time and visualized in third-party applications due to unambiguous coding via e.g. XML format.

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Advantages of IDEA in History Taking

Detailed information collection is the first important step in establishing a constructive relationship with the patient/resident and deriving the nursing care needed. The collection of information in the form of anamnesis is therefore of particular importance, because the accuracy and comprehensiveness of these data influence the next steps (actions, diagnostics, examinations, etc.). The aim of the individual assessment of patients and residents at the beginning of the interdisciplinary treatment process is to find out what needs exist and what kind of support the patient and resident require.

More than 1,400 Coded Text Modules and Additional Free-Text Fields

IDEA provides more than 1,400 coded text modules for various specialist contexts and also offers the option of making individual entries in free text fields which in turn can be retrieved for analysis. The formulation of the system's text modules is based on the relevant expert standards and corresponds to the current state of research. IDEA is also linked to risk assessment scales and records.

Linkages with ICD-10 and OPS Codings

Furthermore, the data collected are already linked to ICD-10 and OPS codes at this level of the history.

Linkages to Nursing Terminologies and Classifications

Furthermore, it is possible to link IDEA with specialist languages and classifications in software – for example, IDEA is already used with linkages to the nursing terminology ENP in European healthcare institutions.

Data Exchange and Benchmarking

The exchange of data for the purpose of avoiding redundant work processes is just as possible with IDEA as a comparison across institutions in the sense of the increasingly required benchmarking.

Triggering Care Processes

IDEA directly triggers the care processes: the support of diagnostics serves as quality assurance - and thus for all parties involved.

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