Evaluation of quality control methods for medical documentation

A retrospective study about the impact of different quality control methods for medical documentation was performed at the Surgical Center II in Essen. The standardized medical documentation was legislative obliged since the first of 1996 and includes diagnoses and surgical procedures. The patient data were taken from the computer-based patient record of the Surgical Center II which is in routine use since 1989. Quality improvement was aimed at with lectures, training, a quality circle, and systematic approaches like feedback and reminder between 1995 and 1996. The results demonstrate that information and training of physicians is significantly less important for the quality of documentation than a departmental and central control. It is advisable to take this results into account introducing new documentation entities and procedures and to provide functionalities For a periodical control soon.