| Foreword to the First German Edition | p. vii |
| Series Preface | p. ix |
| Preface | p. xi |
| What Is Medical Documentation About? | p. 1 |
| What It Is and What It Isn't | p. 1 |
| Medical Documentation: Do We Really Need It? | p. 2 |
| Problems and Motivation | p. 2 |
| More Important Today Than Ever Before | p. 3 |
| What Are the Objectives of Medical Documentation? | p. 3 |
| General Objectives | p. 3 |
| Objectives in Patient Care | p. 4 |
| Objectives in Administration | p. 4 |
| Objectives in Quality Management and Education | p. 5 |
| Objectives in Clinical Research | p. 5 |
| Multiple Use of Patient Data | p. 6 |
| Medical Documentation: Child's Play? | p. 7 |
| Computer-Supported Medical Documentation: A Panacea? | p. 8 |
| Checklist: Objectives of Medical Documentation | p. 8 |
| Exercises | p. 9 |
| Basic Concepts of Clinical Data Management and Coding Systems | p. 11 |
| The Documenting Institution | p. 11 |
| The Physician's Office and the Outpatient Clinic | p. 11 |
| The Hospital | p. 12 |
| Other Relevant Institutions | p. 13 |
| From Attributes to Data Management | p. 15 |
| Objects and Attributes | p. 15 |
| Definitions, Labels, and Terminology | p. 17 |
| Data, Information, and Knowledge | p. 19 |
| Documents | p. 21 |
| Data Management Systems | p. 21 |
| Exercises | p. 22 |
| Clinical Data Management Systems | p. 23 |
| Characteristics of Clinical Data Management Systems | p. 23 |
| Exercises | p. 30 |
| Medical Coding Systems | p. 30 |
| Coding Systems: Why Do We Need Them? | p. 31 |
| What Is a Coding System? | p. 32 |
| Classifications and Nomenclatures | p. 32 |
| A Few Additional Remarks | p. 41 |
| Exercises | p. 41 |
| Important Medical Coding Systems | p. 43 |
| International Classification of Diseases (ICD) | p. 43 |
| The 10th Revision (ICD-10) | p. 44 |
| Extensions to the ICD | p. 46 |
| Procedure Classifications | p. 47 |
| International Classification of Procedures in Medicine (ICPM) | p. 47 |
| ICD-10-Procedure Coding System (ICD-10-PCS) | p. 49 |
| Systematized Nomenclature of Medicine (SNOMED) | p. 52 |
| SNOMED Reference Terminology (SNOMED RT) | p. 53 |
| SNOMED Clinical Terminology (SNOMED CT) | p. 56 |
| The TNM Classification of Malignant Tumors | p. 57 |
| Structure | p. 58 |
| MeSH and UMLS | p. 60 |
| Exercises | p. 60 |
| Typical Medical Documentation | p. 63 |
| The Patient Record | p. 63 |
| Patient Record Archives | p. 65 |
| Clinical Basic Data Set Documentation | p. 66 |
| Clinical Findings Documentation | p. 67 |
| Clinical Tumor Documentation | p. 68 |
| Documentation for Quality Management | p. 69 |
| Clinical and Epidemiological Registers | p. 71 |
| Documentation in Clinical Studies | p. 72 |
| Documentation in Hospital Information Systems | p. 73 |
| Exercises | p. 73 |
| Utilization of Clinical Data Management Systems | p. 75 |
| Patient-Oriented Analysis | p. 75 |
| Patient-Group Reporting | p. 78 |
| Clinical Studies | p. 82 |
| Quality Measures in Information Retrieval | p. 86 |
| Exercises | p. 87 |
| Clinical Data Management: Let's Make a Plan! | p. 89 |
| Planning Medical Coding Systems | p. 89 |
| General Principles | p. 89 |
| Principles of Ordering Qualitative Data | p. 90 |
| Principles of Ordering Quantitative Data | p. 91 |
| Planning Clinical Data Management Systems | p. 92 |
| Why Plan Them at All? | p. 92 |
| The Documentation Protocol | p. 93 |
| Prolective and Prospective Analyses | p. 94 |
| Additional Remarks | p. 94 |
| Example: A Tumor Documentation Protocol | p. 95 |
| Exercises | p. 102 |
| Documentation in Hospital Information Systems | p. 103 |
| The Hospital Information System | p. 103 |
| The Concept | p. 103 |
| The Significance | p. 104 |
| The Need for a Strategic Plan | p. 105 |
| Important Hospital Functions | p. 107 |
| Exercises | p. 110 |
| Management and Operation of Hospital Information Systems | p. 110 |
| The Strategic Plan | p. 112 |
| The Electronic Patient Record | p. 112 |
| What Is an Electronic Patient Record? | p. 113 |
| Advantages and Disadvantages of the Electronic Patient Record | p. 114 |
| Introducing the Electronic Patient Record | p. 115 |
| Methodology of Medical Documentation | p. 116 |
| Data Management in Clinical Studies | p. 117 |
| Therapeutic Trials | p. 118 |
| Good Clinical Practice (GCP) | p. 119 |
| Study Protocol | p. 120 |
| Case Report Forms (CRFs) | p. 120 |
| Monitoring | p. 121 |
| Auditing and Quality Assurance | p. 122 |
| Processing of the Quality Assurance | p. 123 |
| Checking and Correcting Data | p. 123 |
| Classification of Nonstandardized Entries | p. 123 |
| Secondary Data Acquisition | p. 124 |
| Database Closure | p. 124 |
| Analysis | p. 125 |
| Archiving the Trial Master File | p. 125 |
| Checklist: Data Management in Clinical Studies | p. 126 |
| Exercise | p. 127 |
| Concluding Remarks | p. 129 |
| Suggested Further Information | p. 131 |
| General References | p. 131 |
| Standardization Bodies | p. 131 |
| Education in Medical Documentation | p. 132 |
| Professional and Other Relevant Organizations | p. 133 |
| Information on Coding Systems | p. 133 |
| Basic Literature on Medical Documentation | p. 134 |
| Thesaurus of Medical Documentation | p. 137 |
| Documentation Protocol of the Thesaurus | p. 137 |
| Thesaurus Entries | p. 139 |
| Index | p. 197 |
| Table of Contents provided by Rittenhouse. All Rights Reserved. |
