[Documentation in the polyclinic-internal medicine care process]. 1985

K P Wenzel

In five full-time and part-time specialists for internal medicine, respectively, of the district outpatient department the quality of the documentation of the ambulatory care has been tested. The documentations proved to be sufficient. Obviously this or that specialist sometimes keeps away from establishing a tentative diagnosis in the primary consultation. But the making of a preliminary diagnosis involves to do with a limited but sufficient examination programme.

UI MeSH Term Description Entries
D008499 Medical Records Recording of pertinent information concerning patient's illness or illnesses. Health Diaries,Medical Transcription,Records, Medical,Transcription, Medical,Diaries, Health,Diary, Health,Health Diary,Medical Record,Medical Transcriptions,Record, Medical,Transcriptions, Medical
D012017 Referral and Consultation The practice of sending a patient to another program or practitioner for services or advice which the referring source is not prepared to provide. Consultation,Gatekeepers, Health Service,Hospital Referral,Second Opinion,Consultation and Referral,Health Service Gatekeepers,Hospital Referrals,Referral,Referral, Hospital,Referrals, Hospital,Consultations,Gatekeeper, Health Service,Health Service Gatekeeper,Opinion, Second,Opinions, Second,Referrals,Second Opinions
D005859 Germany, East The former German Democratic Republic which was reunified with the former Federal Republic of Germany in 1990. Democratic Republic of Germany,German Democratic Republic,Germany, Democratic Republic of
D006801 Humans Members of the species Homo sapiens. Homo sapiens,Man (Taxonomy),Human,Man, Modern,Modern Man
D000553 Ambulatory Care Health care services provided to patients on an ambulatory basis, rather than by admission to a hospital or other health care facility. The services may be a part of a hospital, augmenting its inpatient services, or may be provided at a free-standing facility. Outpatient Care,Outpatient Health Services,Clinic Visits,Health Services, Outpatient,Outpatient Services,Services, Outpatient Health,Urgent Care,Care, Ambulatory,Care, Outpatient,Care, Urgent,Cares, Urgent,Clinic Visit,Health Service, Outpatient,Outpatient Health Service,Outpatient Service,Service, Outpatient,Service, Outpatient Health,Services, Outpatient,Urgent Cares,Visit, Clinic,Visits, Clinic

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