[Standardized computer-based documentation system for diagnoses and medical performance in orthopedics and traumatology. Development and initial application].

Introduction: Increasing demands on quality assurance und medical performance documentation require an immediate and evaluable documentation in the outpatients' department. Presentation of a new computer-based diagnostic system for reporting and medical performance documentation.

Methods: Development and initial application of the system in three big orthopedical or traumatological hospitals. Judgements about the feasibility of immediate documentation in outpatients' departments.

Results: Presentation of an outpatients' departments diagnostic system with textblock-oriented anamnesis or anatomy-related diagnosis through pre-structured examination checklists. Coding of ICD-9/-10 as well as AO-classification and AIS (abbreviated injury scale). Implementation of scorings. Medical performance documentation through forms including pre-defined billing codes. Presentation of the documentation flow and its transfer into other contexts.

Discussion: Pure text-based clinical results do not allow sufficient evaluation for quality assurance and medical performance documentation. However, a computer-based and immediate documentation in outpatients' departments should not mean a significantly increased workload for physicians.