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Records&QAEasy Services is a private consultancy service, a Companies Commission Of Malaysia registered business enterprise based in Malaysia now available in Malaysia and Worldwide, managed by VIJAYAN RAGAVAN who also manages the Medical Records Pals Malaysia website-blog.

If managing paper based medical Records is a logistical nightmare, if managing electronic health / medical records capabilities in one complete system is your priority, and if managing hospital records to comply with accreditation and your hospital Quality Assurance (QA) management program is like trying to fit a square peg in a round hole, and if your coders need to be trained in disease coding, then engaging Records&QAEasy Services is the pragmatic answer!

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Recent Posts

Global COVID-19 Clinical Characterization Case Record Form

In the wake of COVID-19, I have been thinking how coronavirus data is been captured into a typical medical record. A check around the Internet led me to the World Health Organisation [WHO] recommended rapid clinical characterisation case record form (clinical CRF).

Like the one standardised form i.e. The World Health Organisation (WHO) International Form of Medical Certificate of Cause of Death to collect mortality data among member states—with the clinicial CRF form also by the WHO, the WHO intends that by using one standardised clinical data tool, there is potential for clinical data from around the world to be aggregated; in order to learn more to inform the public health response and prepare for large scale clinical trials.

This form is intended to provide member states with a standardised approach to collect clinical data in order to better understand the natural history of this disease and describe clinical phenotypes and treatment interventions (i.e. clinical characterisation) for Covid-19.

Some important stuff to take note if implementing this form include:

1: this CRF has 3 (M)odules to be completed—(M1)for first day of admission to the health centre, (M2) on first day of admission to ICU or high dependency unit, also be completed daily for as many days as resources allow and continued to follow-up patients who transfer between wards, and (M3) to be completed at discharge or death; and,

2: Internet services are required to enter data to the central electronic REDCap database or to your site/network’s independent database; the form guidelines suggest that printed paper CRFs may be used and the data can be typed into the electronic database afterwards.

The form can be viewed from the link (the link will open in a new tab of your current window) in the reference given below.

Reference:
Coronavirus disease (COVID-19) technical guidance: Patient management, Case Management, WHO, <https://www.who.int/docs/default-source/coronaviruse/who-ncov-crf.pdf?sfvrsn=84766e69_4>

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