title: Recording clinical data--from a general set of record items to case report forms (CRF) for clinics.
abstract: Standardising a documentary language makes only sense if we use it for documentation consequently. Using an example of Paediatric Oncology in Germany we have developed a procedure that generates CRFs from a documentary language. The introduced procedure has proved to be feasible in practice. With it we can support developers of documentation systems in creating their CRFs; through the guaranteed use of the documentation terminology we further achieve that information recorded with the created CRFs may be statistically analysed across different institutions.
authors.affiliation: Institute for Medical Biometry and Informatics, Department of Medical Informatics, University of Heidelberg, 69120 Heidelberg, Germany. angela.merzweiler@gmx.de
authors.forename: A
authors.initials: A
authors.lastname: Merzweiler
authors.forename: P
authors.initials: P
authors.lastname: Knaup
authors.forename: R
authors.initials: R
authors.lastname: Weber
authors.forename: H
authors.initials: H
authors.lastname: Ehlerding
authors.forename: R
authors.initials: R
authors.lastname: Haux
authors.forename: T
authors.initials: T
authors.lastname: Wiedemann
mesh_terms: D002986:Clinical Trials as Topic / Q000592:standards*; D004282:Documentation / Q000592:standards*; D006801:Humans; D008495:Medical Oncology; D016347:Medical Records Systems, Computerized / Q000592:standards*; D015337:Multicenter Studies as Topic / Q000592:standards; D010372:Pediatrics; D009626:Terminology as Topic; D018875:Vocabulary, Controlled