Structured Anamnesis Collection with IDEA
IDEA (Interdisciplinary Data based Electronic Assessment) is for the collection of structured anamnesis information. IDEA is an interdisciplinary, data based anamnesis structure. It is based on the use of standardized knowledge and on the literature based collection of anamnesis information which are linked to various instruments.
- Information
- Advantages
Aims of the Structured AnamnesisAims of the Structured Anamnesis
No data redundancies
Often, anamnesis information of the medical and nursing care are available in unstructured form. This is usually due to handwritten filled in forms, house catalogues and the various professions involved in the collection of anamnestic data. Especially, interviews of the patient on his/her medical history are to some extent repeatedly carried out, and the related collection of e.g. risk factors lead to data redundancies.
No heterogenous data collection
At the same time, the data can not be used interprofessionally, because the different perspectives on the patient and priorities of the professions involved affect the data collection. This heterogeneous collection of data prevents the use of these data in the context of scientific reports on the one hand and the further use of these data for the electronic patient documentation on the other hand. Furthermore, there are no linkages to other instruments using the anamnesis data, for example, scores, diagnostics, instruments for the calculation of nursing time etc.
Structured and unambiguously coded anamnesis data
Against this background, we have developed IDEA. All health-related anamnesis data can be collected in a structured and clearly coded form. Subsequently, the collected data of patients/residents can be retrieved and modified if necessary at any time. The electronically provided information, which are retrievable for all professions involved in the core process, are literature-related and contextual.
Advantages of IDEA in anamnesis collection
A comprehensive nursing information collection is the first important step to establish a constructive relationship with the patient/resident and to derive to the required nursing activities. The collection of information in the form of anamnesis is especially important, because accuracy and comprehensiveness of these data affect 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 requires.
More than 1,400 coded text blocks and additional free-text fields
IDEA provides more than 1,400 coded text modules for various specialist areas and also offers the opportunity to make individual entries into free text fields which can be retrieved for analysis. The formulation of the system's text modules complies with the respective relevant expert standards and reflect the current state of research. IDEA is linked with charts for risk evaluation.
Linkages with ICD-10 and OPS codings
There is also on this level of the anamnesis a linkage between the collected data with ICD-10 and/or OPS codings.
Linkages to nursing languages and classifications
Furthermore, it is possible to link IDEA with specialist languages and classifications in software – IDEA, for example, is already used with linkages to the nursing language ENP in European healthcare institutions.
Data exchange and benchmarking
With IDEA, the exchange of data is possible to avoid redundant work processes as well as comparisons across institutions in the sense of an increasingly required benchmarking.
Initiation of treatment processes
IDEA initiates treatment processes directly: the support of diagnostics provides for quality assurance - and thus for all professionals involved.