title: Structured clinical documentation for the assessment of medical care.
abstract: The developing infrastructure for tumour documentation in Germany offers the unique opportunity to provide the physicians with useful clinical information, to evaluate standards of care, and get an impression about the "real-world-effectiveness" of cancer care. In order to compare and evaluate diagnostic and therapeutic approaches in different medical institutions or health care systems, the systematic, patient-oriented, treatment accompanying tumour documentation is a compelling requirement. Our intention is to optimise content and extent of the collected information to characterise the different dimensions of the quality of medical care the best possible. We found that most of the problems are deriving from the contextually and timely correct documentation of medical procedures which includes diagnostic as well as therapeutic interventions. The content of the documentation together with standards of care, such as Clinical Practice Guidelines, should be parallel developed in interdisciplinary co-operation. This way, the fundamental domains of performance, such as appropriateness, availability, continuity, safety, effectiveness, and timeliness of medical care can described and evaluated objectively.
authors.affiliation: Institute of Medical Informatics, Justus-Liebig-University, Giessen, Germany.
authors.forename: S
authors.initials: S
authors.lastname: Hölzer
authors.forename: W
authors.initials: W
authors.lastname: Wächter
authors.forename: U
authors.initials: U
authors.lastname: Altmann
authors.forename: R
authors.initials: R
authors.lastname: Schweiger
authors.forename: J
authors.initials: J
authors.lastname: Dudeck
mesh_terms: D004282:Documentation / Q000379:methods*; D005858:Germany; D006801:Humans; D016347:Medical Records Systems, Computerized; D009369:Neoplasms / Q000628:therapy*; D010348:Patient Care Team; D017410:Practice Guidelines as Topic; D011785:Quality Assurance, Health Care