title: [Analysis and assurance of complete medical documentation].
abstract: A written report on the findings of the examination forms the basis for the further procedure in the treatment of a patient--not merely in the area of orthopaedics. The examination findings should, therefore, be legible, readily understandable and complete. On the basis of 600 individual findings established at admission in the case of inpatients with diseases of the spine and hip, stemming from a total of three hospitals, the behaviour pattern of the individual examiner is analysed along with deficiencies in documentation. For a number of significant deficits, differences in the particular emphasis applied by individual physicians during the examination, the fact that the time available for such examinations is usually limited, and the lack of documentation system, are probably responsible.
authors.affiliation: Orthopädische Universitäts- und Poliklinik Essen.
authors.forename: R T
authors.initials: RT
authors.lastname: Müller
mesh_terms: D003625:Data Collection; D004282:Documentation / Q000379:methods*; D006801:Humans; D007405:Intervertebral Disc Displacement / Q000175:diagnosis* / Q000601:surgery; D017116:Low Back Pain / Q000175:diagnosis* / Q000601:surgery; D008159:Lumbar Vertebrae; D016347:Medical Records Systems, Computerized; D009460:Neurologic Examination; D015207:Osteoarthritis, Hip / Q000175:diagnosis* / Q000601:surgery; D011183:Postoperative Complications / Q000175:diagnosis; D011785:Quality Assurance, Health Care; D016059:Range of Motion, Articular
vernacular_title: Analyse und Sicherung der ordnungsgemässen ärztlichen Dokumentation.