Die ?Erweiterte Basisdokumentation operierter Krebspatienten? in Therapie und Nachsorge

Abstract

Presented is a program of recording all facts in the fate of a cancer patient relevant for therapy and prognosis in a manner suitable for EDP. Beside optimal medical treatment it is the substance of the documentation system to produce the complete pathogram of all registered cancer patients. From the day of establishment of the diagnosis and the begin of clinical treatment in the Evgl. Krankenhaus up to the following 5 years the cancer patient runs through a strongly termed and tumor specific follow-up. All informations and facts are registered in a codable medical record, a basic documentation for tumor patients, a follow-up and a final questionaire. In the so coded pathogram of the cancer patient we only use international binding classifications and coding systems. The pathogram is the result of a longer development and testing time in the surgical department of a smaller hospital. The presented principles of documentation include all basis necessary for the establishment of a clinical cancer registry and documentation follow-up.