Struktur statt Chaos: So gelingt der perfekte Diagnosekopf im Entlassbrief

The diagnosis section in discharge letters (in some countries also referred to as problem list) plays a crucial role in ensuring continuity of care, yet its quality often falls short. While 96% of German physicians report that the diagnosis section is essential for safe and effective follow-up care, only 37% are satisfied with their quality. Deficiencies include lack of ICD-10 codes, ambiguous abbreviations, and unstructured layouts caused by blind copy-pasting from previous reports, time pressure, and the absence of documentation standards.This article presents practical, physician-endorsed recommendations for writing concise, structured, and clinically relevant diagnosis sections. According to consensus amongst physicians, diagnoses should be structured in three segments: 1) current treatment diagnoses, 2) chronic conditions, and 3) previous diagnoses. A checklist for improving documentation quality is provided and a vision for the future outlined: disease-specific templates that can be integrated as Medical Information Objects (MIOs) into German electronic patient records.