Abstract

Five years after implementation of a medical documentation assistant (MDA) as a pilot project in our trauma department, this paper examines the results. We evaluate practice and integration in our daily ward/department work. The measurable parameter or "value" of the MDA is the settlement reserve demonstrated as the cost weight (CW) for better demonstration of performance. The MDA is now an essential part of the daily routine in our department. In addition to the advisory function in codifying medical services, relevant secondary diagnoses are documented and clinical progress is checked to identify additional profitable services. We thus achieve an average additional monthly CW benefit of 11.4046. We have not yet assessed the improved documentation of medical records, which is especially important when checked by the medical service of the health fund. Furthermore, half of the hours of one doctor can thus be saved and therefore used for proper medical activities every day.

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