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Table 3 The data categories (and items) required for support of CKD patients by an ePHR

From: Patient empowerment through a user-centered design of an electronic personal health record: a qualitative study of user requirements in chronic kidney disease

Category

 

Data items

Demographic information

Patient demographics

First and last names, gender, national identification number, date of birth, marital status, job, contact numbers, address and postal code

Demographics of patients’ care-givers

First and last names, gender, relation to the patient, emergency phone number, address, postal code

Demographics of patients’ care providers

First and last names, types of care provider (e.g., nephrologist, nurse, internal medicine specialist, general practitioner/family physician, clinic secretary, medical intern or resident), work address, contact number

History of patient's CKD

Clinical history specific for CKD

The main cause of CKD, stage of the disease, the date of first CKD diagnosis, history of kidney biopsy

History of RRT

General RRT information

Kidney transplant/dialysis status, the method of dialysis

Clinical history of hemodialysis patients

Type of vascular access (including graft, fistula, temporary catheter or permacath), vascular access insertion date, start date of hemodialysis, frequency of hemodialysis per week, the address of hemodialysis unit

Clinical history of peritoneal dialysis patients

Peritoneal catheter insertion date, start date of peritoneal dialysis, peritoneal dialysis frequency, exit-site status/infection, history of peritonitis

Clinical history of diabetic patients

History of diabetes, diabetic retinopathy, diabetic ulcer (condition and place)

General medical history

Lifestyle

Height, weight, history of alcohol use, history of smoking, other comorbid diseases

Allergies

Medication allergies, food allergies, other allergies

Hospital admission/medical procedure history

Internal units admission

Admission date, discharge summary

Medical procedures

Result of the last echocardiography, admission date, proceadure summary

Family history

 

First and last names, relation to patient, type of disease

Diagnostic tests

Biochemical tests

 

CBC, Creatinine, BUN, FBS, HbA1c, ALT, AST, ALP, Bili-T, Bili-D, TG, Chol, LDL, HDL, Calcium, Phosphate, iPTH, Vit D, Sodium, Potassium, Ferritin, TIBC, Iron, HBsAg, HCV Ab, TB, PSA, ESR

Diagnostic radiology tests

 

KUB, CXR, CT-Scan, MRI, Sonography

Medications

 

Medication name, form, and dosage, time of medication intake, start time of medication, stop time of medication

Training/education

 

System user instruction, education materials for important medications, nutrition, lifestyle, and hemodialysis and peritoneal dialysis; training session for recommendation of family member screenings in specific conditions, frequently asked questions

Daily reports

Information of fluid intake limitation

Fluid intake volume and date, volume of urine, other fluid input/output volumes

Daily clinical symptoms

Hypertension information

Systolic and diastolic blood pressure values with dates

Glucose information for diabetic patients

Glucose values with time/date

Scheduled information

  

Date of an upcoming follow-up visit, date of due medical laboratory, date of due laboratory results, date of due vaccination

  1. CKD chronic kidney disease, RRT renal replacement therapy, CBC complete blood count, BUN blood urea nitrogen, FBS fasting blood sugar, HbA1c Hemoglobin A1c, ALT alanine aminotransferase, AST aspartate aminotransferase, ALP alkaline phosphatase, Bili-T bilirubin total, Bili-D bilirubin direct, TG thyroglobulin, LDL low density lipoprotein, HDL high density lipoprotein, iPTH intact parathyroid hormone, Vat D vitamin D, TIBC total iron binding capacity, HBsAg Hepatitis B surface antigen, HCV Ab Hepatitis C virus antibody, TB tuberculosis, PSA prostate specific antigen, ESR erythrocyte sedimentation rate, KUB kidney, ureter, and bladder, CXR chest X-Ray, CT-Scan computed tomography-scan, MRI magnetic resonance imaging