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The clinical audit process seeks to identify areas for service improvement, develop & carry out action plans to rectify or improve service provision and then to re-audit to ensure that these changes have an effect. Clinical audit can be described as a cycle or a spiral, see figure.
A case report form (or CRF) is a paper or electronic questionnaire specifically used in clinical trial research. [1] The case report form is the tool used by the sponsor of the clinical trial to collect data from each participating patient.
Continuity of Care Document - The Continuity of Care Document (CCD) represents a core data set of the most relevant administrative, demographic, and clinical information facts about a patient's healthcare, covering one or more healthcare encounters. The primary use case for the CCD is to provide a snapshot in time containing the germane ...
In the second stage of meaningful use, the CCD, but not the CCR, was included as part of the standard for clinical document exchange. [9] The selected standard, known as the Consolidated Clinical Document Architecture (C-CDA) was developed by Health Level 7 and includes nine document types, one of which is an updated version of the CCD. [2]
A history (audit trail) must be maintained of changes and deletions to electronic versions [2] [4] [5] Supporting documents can be added to the original document as an attachment for clarification or recording data. Attachments should be referenced at least once within the original document.
An XML element in a CDA supports unstructured text, as well as links to composite documents encoded in pdf, docx, or rtf, as well as image formats like jpg and png. [ 3 ] It was developed using the HL7 Development Framework (HDF) and it is based on the HL7 Reference Information Model (RIM) and the HL7 Version 3 Data Types.
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The Alcohol Use Disorders Identification Test (AUDIT) is a ten-item questionnaire approved by the World Health Organization to screen patients for hazardous (risky) and harmful alcohol consumption. It was developed from a WHO multi-country collaborative study, [ 1 ] [ 2 ] [ 3 ] the items being selected for the AUDIT being the best performing of ...