Guide for checking charts

event requested source documents report first or any event? appropriate checking chart

low trauma fracture

all requests according to the diagnostic criteria mentioned on checking chart

any

low trauma fracture

invasive cardiovascular procedures
  • coronary artery by-pass grafting
  • coronary angioplasty / stenting
  • carotic endarterectomy
report of intervention any cor. angio./by-pass
stroke
  • haemorrhage
  • infarction
  • subarachnoideal haemorrhage
  • unknown
hospital report (description of the duration of symptoms is necessary) any stroke
myocardial infarction hospital report

up to 4 ECGs

any myocardial infarction
end stage renal disease
  • haemodialysis
  • peritoneal dialysis
  • kidney transplantation
hospital report

histology report (for dialysis information if lasting more than 3 months)
first of these events only renal disease
end stage liver disease
  • bleeding from gastric or
    esophageal varices
  • hepatic encephalophathy
    stage III or IV
  • hepatorenal syndrome
  • ascites
  • liver transplantation
hospital report (describing
symptoms) or
report of transplantation

report of liver biopsy or
of fibroscan
first of these events only liver disease

diabetes mellitus

all requests according to the diagnostic criteria mentioned on checking chart

first diagnosis

diabetes

cancer
  • AIDS-defining
  • others, with the exception
    of non-melanoma skin cancers

histology report

if not available
imaging report or
hospital report

first diagnosis of each type of cancer (not relapse) cancer