Documentation. Prerequisite for quality management

For the judgment of the quality of medical services and for the progress of clinical medicine the comparison of data and informations of the diagnosti c and therapeutic process is demanded. Therefore a systematic and concrete system of documentation should be implemented in every clinic, which consis ts of standard nomenclature, classification, instruments of outcome measure and documentation standards. There are a group of problems and barriers wh ich stand in the way of this goal. It is useful to build a minimum basis da ta set which includes core criterias of clinical dokumentation in orthopedi c surgery and include this in an information system so that all of these pa rts are considered and that a central and comparable data pool is offered f or patient care, quality management and research.