A medical record might include more information, such as
A structured medical record will use fixed terminology, rather than free text. In this diagram, the terminology is drawn from CDISC controlled terminology and the CTCAE code system.
SDTM was originally designed for data from clinical trials submitted to regulators. This means that the person is not identified by personally identifiable information, but by a study identifier assigned as part of the study in which they participated.
A test conducted for a clinical trial is usually performed according to the study protocol during a particular visit, and may be performed at a particular time point. SDTM timing variables may be used to represent the timing of the test