[Documentation. A prerequisite for quality management].

Abstract

For the judgment of the quality of medical services and for the progress of clinical medicine the comparison of data and informations of the diagnostic and therapeutic process is demanded. Therefore a systematic and concrete system of documentation should be implemented in every clinic, which consists of standard nomenclature, classification, instruments of outcome measure and documentation standards. There are a group of problems and barriers which stand in the way of this goal. It is useful to build a minimum basis data set which includes core criteria of clinical documentation in orthopedic surgery and include this in an information system so that all of these parts are considered and that a central and comparable data pool is offered for patient care, quality management and research.