[Documentation in the polyclinic-internal medicine care process].
In five full-time and part-time specialists for internal medicine, respectively, of the district outpatient department the quality of the documentation of the ambulatory care has been tested. The documentations proved to be sufficient. Obviously this or that specialist sometimes keeps away from establishing a tentative diagnosis in the primary consultation. But the making of a preliminary diagnosis involves to do with a limited but sufficient examination programme.
D000553:Ambulatory Care; D005859:Germany, East; D006801:Humans; D008499:Medical Records / Q000592:standards*; D012017:Referral and Consultation
Dokumentation im poliklinisch-internistischen Betreuungsprozess.