Medical documentation

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The aim of medical documentation is to organize information and knowledge about clinical pictures and treatment methods ( types ) and for the individual cases of individual patients ( instances ) in such a way that medical care can be supported in the broadest sense. The medical documentation collects information not only from patients, but also from healthy people, provided they are e.g. B. be examined systematically (example screening for diseases).

The medical documentation is also evidence for the billing of services. It must therefore be revision-proof according to SGB ​​V and, in the event of liability, legally binding .

Medical documentation for certain clinical pictures

This quality of medical documentation does not name individuals, but rather describes the characteristics of clinical pictures and the corresponding treatment methods as types .

The medical societies publish national medical guidelines in the national languages . In Germany there are around 800 such guidelines in a joint database. In the USA there are around 1800 such guidelines in a common database. Only these have an overview of the guidelines of the individual professional associations.

  • Guidelines
  • Expert recommendations
  • Catalogs
  • Classifications
  • Etc.

methodic procedure

The medical documentation is used in particular with anonymized data in data comparisons and evaluations for reports and studies

  • for quality management in methodological and epidemiological research
  • for the assessment of medical care in health services research
  • for the determination of the outcome achieved with the known methods in favor of the patient

The medical documentation creates, for example:

  • the documentation of medical data in individual cases, d. H. Results of medical observations or examinations on individual patients
  • the synoptic documentation of medical findings in scientific work , d. H. Results of methodological investigations known or new procedures for typical clinical pictures from a patient group
  • A selection of clinical treatment pathways in the methodical management of a clinic .
  • for technical support of clinical work together with the technical disciplines classifications , catalogs , standards and norms
  • together with the business management of the clinic, cost models and rules for coding the medical service.

Medical documentation uses, for example:

  • Methods of scientific work to document medical knowledge (e.g. publications in reports, journals and other literature).
  • Medical informatics method for recording, collecting, organizing and compressing medical data

Methodological justification

The field of medical documentation is represented by the German Association of Medical Documentaries and has close relationships with the GMDS ( German Society for Medical Informatics, Biometry and Epidemiology ). The methodological suggestions of the professional societies are usually limited to the medical content according to the generally recognized state of medical science . This is determined by the consensus of the universities and research institutes.

Both lay no minimum requirements for the technical handling firm, this task is regularly providers appropriate content management systems as well as international bodies of standardization and standardization to and through the general competition and the recognized state of the art determined.

Creator of the scientific documents

This type of documentation is usually anonymized. In particular, the study documentation follows precisely defined rules in order to obtain approval from specialist colleagues and approval from the supervisory authorities, for example, for a new drug or a new treatment method. For this purpose, before the start of a study, it is precisely determined which documents are to be created and how in detail the information to be collected from the study is to be recorded and recorded. For this purpose, content management systems are usually used to ensure consistency and completeness.

Tasks in individual cases

This quality of medical documentation only affects individuals, i.e. individual patients, and describes the diagnosed features of recognized clinical pictures and the correspondingly selected treatment methods for treating the same patient as types . This individual medical documentation is used in particular for each individual case:

  • the organization of patient care according to the state of medical science and technology
  • the contractual and legal documentation requirements
  • the operational accounting in the establishment of the service providers and the service accounting towards the cost providers

Components of the documentation in individual cases

The treatment of a patient is documented as a closed case . The summary of several such case documentation results in parts of a medical history . The summary of the documents of several facilities for the individual case is done physically by collecting the documents as soon as possible when information is gained in the treatment of the patient.

Medical documentation includes all records relating to the treatment of the patient in each individual case, such as

and in summary the

Methodological justification

The professional quality of the individual documentation is also represented by the German Association of Medical Documentaries and has close relationships with the specialist society GMDS ( German Society for Medical Informatics, Biometry and Epidemiology ). The methodological suggestions of the professional associations are usually limited to the medical content and do not stipulate any minimum requirements for technical handling. This task is regularly the suppliers of the corresponding hospital information systems as well as international bodies of standardization and standardization to and is determined by the general competition and the recognized state of the art.

Creator of the individual documents

Medical documentation takes place partly as part of medical work (including auxiliary professions such as nurses and medical assistants). The main professional activity is carried out by medical documentaries, documentation assistants and specialists for media and information services specializing in medical documentation. In Germany there are, among other things, the training courses for medical documentaries and medical documentation assistants , as well as technical college courses leading to a diploma documentary (FH) or bachelor's degree.

The medical documentation also serves as evidence to protect the doctor and the nurse that they have carried out their work in accordance with ethics and law and in accordance with the contract. The documents should provide a good overview and make processes comprehensible for outsiders. Hospital information systems are used regularly to ensure authenticity , consistency and completeness. An exclusively paper-based documentation in text sheets, note sheets and pictures no longer corresponds to the state of the art and also does not correspond to the objectives set out in the German Social Code ( SGB ​​V and SGB ​​X ).


The coding of medical information has been a methodological approach for improving the clarity of information about a group of patients, which has been prescribed by the WHO of the UN and is standardized with the international classification of diseases ICD since the 1990s . To date, the support of clinical information systems for such classifications is so weak that the corresponding requirements are first and foremost understood as a burden on medical work. Nevertheless, it is unmistakable that medical statistics and the epidemiology based on them determine the basis for the provision of funds for new areas of research.

With the introduction of systems for coding medical services, this burden was increased significantly for business purposes and especially for accounting purposes of statutory health insurances , without the individual patient having a measurable benefit, i.e. increasing the outcome . Publications on the effectiveness of such coding only end in the bare and as yet unproven assumption of an advantage for the community of insured persons. This fundamentally contradicts the general requirement for evidence-based medicine .

National solutions

The handling of medical documentation is regulated by country.


The methodological approach in Germany is indirectly defined by traditional actual practice. There is no rational justification for the usefulness of the diverse, special and mostly unrelated solutions. A summary of the medical history that applies to the individual case or even goes beyond the case has not yet been systematically regulated in Germany.

The German Institute for Medical Documentation and Information (DIMDI) has not yet made any specifications on the medical content of medical documentation that go beyond central registration of data, uniform nomenclature and systematic classification.

The year 2003 in Germany after the SHI Modernization Act introduced and by the Institute for the Hospital Remuneration System , written as InEK GmbH methodically guided coding of medical services of medical documentation is only indirectly. It does not create any additional medical content, but rather formalizes the medical documentation as well as the basis for billing and summarizes the individual services in a system of flat rates. As a result of the critical examination by the Medical Service of the Health Insurance (MDK) according to the Social Security Code ( SGB ​​V ), an examination of the coding leads in many cases to a correction or addition to the doctor's letter. This remains the central evidence of the service provided in the flat-rate billing. However, the doctor's letter does not promptly document the authentic occurrence in the treatment of the patient, nor does the coding provide any added value to the individual outcome for the patient.

United States of America

In the USA, the national health institute proposes a personal medical record that every patient can voluntarily compile and keep in a secure database or be handed over.

United Kingdom

The National Health Service maintains an inventory for all patients in England, Scotland, Wales and Northern Ireland. After various breakdowns in several areas of the British government, the Protection of Vulnerable Adults (POVA) scheme has been in place for the health administration since 11 November 2010 for the protection of health data .


The national health service in Sweden maintains a central database for all patients, which is accessible to all treating doctors at any time.


  • Medical documentation. Basics of Quality Assured Integrated Health Care - Textbook and Guide . Schattauer / KNO, ISBN 3-7945-2265-6

Web links

Individual evidence

  1. History of ICD (PDF; 152 kB)
  2. ^ German Institute for Medical Documentation and Information Homepage
  3. Inek GmbH ( Memento of the original from December 9, 2010 in the Internet Archive ) Info: The archive link was inserted automatically and has not yet been checked. Please check the original and archive link according to the instructions and then remove this notice. @1@ 2Template: Webachiv / IABot /
  4. ^ Personal Health Record
  5. ^ British Health Administration Homepage
  6. POVA Scheme download (PDF; 90 kB)
  7. Protection of Vulnerable Adults (POVA) scheme
  8. ^ Socialstyrelsen Stockholm Sweden
  9. ^ Socialstyrelsen Contact