Information technology in a clinic of internal medicine

The information technology of a medical unit has an important effect on structure and quality of medcine based on it. The structure of such a unit has to be optimized, as it is shown by business process reengineering. Nevertheless, medical documentation is the main job managed by am information system in medical units. Most of economic demands are satisfied by structured medical findings or states. Quality assessment also needs a sufficient medical documentation. The doctor himself depends critically on fast, complete and correct information. The summary of twenty years of IT in a clinic of internal medicine shows the farmer DIS I as a valuable documentation-system. The following DIS II made some enlargement necessary. Therefore we completed our documentation with a modul for the encoding of diagnoses with SNOMED, and an automatical generation of structured medical texts.