Medizinische Dokumentation im Neuen Gesundheitswesen

Tasks and goals of documentation include complete, current, standardized, structured, and comprehensible descriptions of different kinds of facts. The adjectives are defined. Many different persons (patients, physicians, nurses, and others) and many different institutions (hospitals, doctors' offices, institutes, companies, insurances, and others) collect and process medical data. Needs and authorizations in this area are investigated. Documentation techniques vary according to goals, persons or institutions involved, or security level and must be defined and specified respectively. These factors will be discussed in the context of the «new health care system» (shared care), for example the question of ownership of patient medical records