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.
In this collaboration, sizeable efforts were allocated for the collection, documentation and uniform classification and coding of morbid events leading to hospitalizations.
There is significant literature that deals with the first two, but very little regarding the systems we use, or how the inadequacies in documentation, identification and classification of VTE affect the cancer patients themselves.
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).
The proportion of people who had clear documentation of risk classification, and for whom the auditor did not need to apply the algorithm, increased from 56% (87/154) in 2008 to 71% (103/145) in 2009 and 76% (118/156) in 2010 (p < 0.001).
