[Orthopedic basic documentation: requirements of diagnostic statistics and results in Göttingen university clinics]

For the first time the revised "Bundespflegesatzverordnung" (Federal Statutory Instrument on Hospital Care Rates) of 1985 has ordered all the hospitals in the F.R.G. to prepare annual statistics of diagnoses giving as part of the anonymous hospital statistics an overview about the medical variety of inpatients and enabling scientific evaluation of cases. The most important documentation items are patient's age, duration of stay, main diagnosis encoded according to ICD-9, and operation characteristic (whether or not any of the operations was carried out because of the main diagnosis). The computerized Goettingen documentation comprises all 15 items of the Minimum Basic Data Set of the European Communities and a few other additional details. The result is a comprehensive and in many directions useful medical documentation for which examples are given.