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Electronic case report forms

Clinical data are entered via electronic forms instead of classic (paper) ones, thus facilitating data trasfer and communication among the involved centres.

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 [MT] 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 entry identification determines the patient diagnosed with MT and his condition at the time of start of medical care. Moreover, these records will make it possible to evaluate the general and universally available basic risk factors, as well as the anamnestic examinations, acquired at the patient's entry to the health care facility.

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. This is essential information in an integral and parametric form, which cannot be found elsewhere in the documentation. Given its central position in the whole system, the minimum continuous record represents a significant linking element for data from various phases of the therapy. The link to the minimum continuous record will always determine the phase of medical care in which the given parameter was evaluated, and thus its interpretation value, too. The minimum continuous record consists of the following components:

  • Primary diagnosis
  • Preceding treatment of prostate carcinoma
  • Patient's overall physical condition
  • Hormone refractory prostate cancer (HRPC)
  • Laboratory values
  • Follow-up
  • FACT-P sheet
  • Quality of life

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