: Ide, R.; Kirste, T.; Lange, M.

Abstract
The foundation of clinical diagnosis and therapy planning is the comprehensive recording of a patient's medical history and examination findings. Even in the age of digital data processing, paper-based media such as forms, the patient's file card etc. are used for the initial on-site recording of this information. In order to allow for computer-based processing of the data, a secondary recording step is required, in which the data is manually transferred from paper-based to electronic media. Such a two-step approach has inherent disadvantages: it requires more man-power, increases the probability of errors, and delays data availability. In order to address these problems, for almost three decades computer-based information systems have been developed and implemented in health-care settings.