[Clinical basic documentation in surgery].

Clinical basic documentation allows a cost lowering and personal saving application of modern data processing technology within the clinical routine. The concept presented in this article has been successful for ten years. Soon after its installation this documentation provides its user with valuable data for internal quality control. Listings of diagnosis, surgical procedures, length of stay and frequencies of complications can be created without extensive knowledge of data processing and computer programming. Based on this concept special documentations for statistical analysis of certain patient groups or diseases are easily established.