[Documentation and quality assurance in clinical routine]

Quality assurance by documentation in the clinical routine may no longer be regarded as a tedious additional duty providing only little practical value in medical care. This leads to users' resistance and to statistics of doubtful validity. Therefore, the great significance of the primary medical documentation for the quality assurance has to be emphasized and should be the focus of an efficient documentation-management. Requirements for such a documentation-management are described and their implementation in the Albertinen-Haus is shown. This institution uses conventional paper-documents as well as their electronic counterparts. An efficient documentation-management shows the advantage of a quality assurance for the daily routine in hospitals. Data required for the statistical quality assurance should merely be a by-product of the usual documentation. This can only be achieved by an increased computer-support in the clinical routine, but it also requires programmes which fill the needs of all the team members.