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Technology Electronic case report forms

Minimum identification record

Minimum identification record is one component defining the basic framework of the electronic documentation (the other component is the minimum continuous record). It involves mainly the primary identification of the patient and of his disease in a basic set of parameters, which can be determined at the patient's entry to the health care facility. These records include, among others, a description of the patient's condition at his first visit to the health care facility. Most of the parameters included in this dataset do not change with time (patient's identification, malignant tumours in the past etc.). Within the modular composition of the whole parametric documentation, these records are obligatory and superior to the detailed description of the therapy, medical procedures, complications and treatment results.

Minimum continuous record

The minimum continuous record is the most important component in the modular composition of the parametric documentation. Along with the minimum identification record, it makes the second part of the basic framework of the documentation, i.e. the "core" to which other records will be related. The minimum continuous record defines the individual phases of medical care, their input and output characteristics, as well as a general plan of the therapy.

 

The detailed structure of parametric documentation is available for download (in Czech language only).
[ PDF file, 234 kB]