[Requirements for documentation by the physician].

Abstract

Medical documentation, which is required by law, serves various purposes: for therapy, to provide information to other physicians who are or may be involved; as a record if there is any disagreement with a patient; and for invoicing purposes. Depending on which of these aspects is being addressed, the documentation is expected to satisfy different demands. With regard to liability, any information pertaining to the patient's medical condition should be recorded as soon as possible in correspondence to the principles of truth and clarity. For the health insurance companies, all treatments and services rendered must be submitted in writing. The power of proof of medical documentation is understood differently from the point of view of liability and health insurance law.