[Basic medical documentation with ID DIACOS as an instrument for quality assurance]

Standardized methods and instruments of medical documentation are prerequisites for quality assurance in medicine. Support for quality assurance measures at present can be attained by the programme systems ID DIACOS (encoding of diagnoses into ICD-9 and procedures into ICPM-GE) for daily clinical routine documentation. Administrative statistics, e.g. the L1-statistics of diagnoses according to section 16 Federal Statutory Instrument on Hospital Care Rates (BPflV) can be compiled without waste by aggregation. Supplementations of the programme system are planned caused by the introduction of new forms of Hospital reimbursement with changed classification patterns. An increasing need for computer-aided encoding will also result by the implementation of new classifications, e.g. ICD-10 and by the requirements concerning a scientific basic documentation (Selbmann, 1990; Mau, 1990) based partly on nomenclatures. The connection of the programme systems ID DIACOS and SNOMED (empirical and morphological analysis of medical texts) is possible and will be carried out (Hultsch, Diekmann, Ruhl, 1990).