OverviewThe Patient Record (also Patient Record Template) is a structure with a flexible number of patient information items. This structure not only contains the patient information, but also information about its structure, so that it is internally known that for example some name is actually the last name of a patient.
DetailsA patient record contains a list of items with information about a patient or research subject. Because patient information strongly differs per country and even per hospital, the structure of the data is user defined.
What happens if a new patient is entered into the data manager, is the following:
The patient management system loads an empty patient record from disk. This record is called the Patient Record Template. It is actually not any different from a filled out record; it just comes without any patient data.
The empty record is then displayed to the user that enters the patient data. The patient management system will then store the filled out record to disk, or to some place as is defined for the management system.
Since the patient record is actually a filled out template, all the structural information of the record is contained in the record for every patient. Should you import a patient record from another hospital or research environment, then it is well possible that the record structure is different. This is not a problem, because the data manager will always show only the structural information for that patient - independently from the record template that has been defined for your own system.
Basic structure of the patient recordEvery information item in the patient record basically contains three parts:
- the caption of the item, for example "Last name".
- the actual value, for example "Johnson".
- a technical name for the item, for example "LastName".
If a form to fill out patient data is displayed, then the caption and value are always displayed together. So, the caption should be readable text for the end-users, probably in the language of the end-user system.
The technical name is never displayed publicly. Nevertheless, it is used by applications that need to read or modify any patient data.