[Rheumatism documentation--a uniform, modular documentation system for therapeutic studies in rheumatic diseases]

Being progressive and also involving variations in the severity of symptoms, chronic rheumatic diseases present difficulties with respect to documentation. Since dramatic changes in the course of disease are rare, early detection of very slight changes is essential to successful antirheumatic therapy. Practical means of documentation are necessary if an overview of the various clinical findings and subjectively reported symptoms is to be maintained over a period of many years. This is especially true in the case of therapeutic studies. The documentation form should enable the recording of suitably grouped data on the various rheumatic diseases and modes of therapy. With governmental support (BMFT project MT 0289), a uniform documentation form, "Dokumentation Rheuma", was set up and tested at 14 hospitals for rheumatic diseases. The modular form chosen and the definition of items were well received by the clinicians. After several modifications, a modularly structured documentation system is now available, elements of which can be expanded according to the needs of the individual therapeutic study. The form can both constitute a part of the patient history and act as a link between different but parallel-running studies, thus making it unnecessary to record the same information twice for different purposes. At the same time, the data base can be used to answer scientific and epidemiological questions independent of the study in progress.