title: [Diagnosis--therapy and documentation].
abstract: The procedures of documentation of diagnostic findings are well established--but different in their graphical and structural appearance of patients histories. Out of multiple findings a retrieval with valid informations is very clumsy. In order to increase quality a complete and reliable registration of clinical data base is necessary. For this purpose the use of electronic media is profitable if the requirements of the data-base are well defined. A nationwide agreement on one key-system--including the transformation of textual structures--is proposed. Only this way leads to comparable results in therapeutic procedures.
authors.affiliation: Orthopädische Universitäts- und Poliklinik, Frankfurt/Main.
authors.forename: W
authors.initials: W
authors.lastname: Schaub
authors.forename: W
authors.initials: W
authors.lastname: Thoma
authors.forename: M
authors.initials: M
authors.lastname: Volke
mesh_terms: D003625:Data Collection; D003627:Data Interpretation, Statistical; D003933:Diagnosis; D004194:Disease / Q000145:classification; D004282:Documentation / Q000379:methods*; D006751:Hospital Information Systems; D006801:Humans; D008492:Medical Informatics Computing; D016347:Medical Records Systems, Computerized; D011785:Quality Assurance, Health Care; D012984:Software; D013812:Therapeutics
vernacular_title: Diagnose--Therapie und Dokumentation.