Next to the outcome measures, a case record form is developed including sociodemography (age, gender, social economic status), cancer and cancer treatment (TNM and ICD-10 classification, documentation of surgery and (chemo radiation), and co-morbidity (Adult Comorbidity Evaluation 27 (ACE-27) test).
Definitions, classification, and documentation are substantive challenges to comprehensive event capture.
Materials selection methods by free searching consist in four steps: translation, filtration, classification and documentation.
Heterogeneity can be explained by the lack of an established evidence-based classification system for documentation and classification of complications in a standardized manner.
In addition, it is necessary to develop a clear set of regulations regarding the entire process of documentation, classification, coding, data processing and collection of patient-level clinical information.
Factor 3. Documentation and classification.
Table 4 Factorial loads, means and standard deviations of SRLTU items for the third factor, "Documentation and classification" Factorial load M SD 8.
Data were organized according to diagnosis, supporting documentation, etiological classification, clinical signs and symptoms (including pain patterns and duration, and quality of life), past medical history, family history, environmental exposures (including alcohol and tobacco use), medication use and therapeutic interventions.
The absence of familial cases might rely, at least in part, on insufficient documentation and classification of spontaneous or induced abortions (Castilla et al., 2008).
Another limitation is the retrospective study design which may not reflect the true incidence of complications due to errors in documentation of classification.
Except for the two indicators "Documentation of risk classification in clinical record" and "Documentation of risk classification in the clinical record summary sheet" all risk classifications are based on documented risk classification where available or, if there was no clear documented risk classification, assessment by auditor applying an algorithm to clinical data available in the record.
