ID

18734

Beschrijving

ODM Form derived from: https://ictr.wisc.edu/CaseReptTempt. Template Name: Physical Examination. Case Report Form (CRF)/Source Document templates were created for University of Wisconsin-Madison researchers. These templates are consistent with the FDA's CDASH (Clinical Data Acquisition Standards Harmonization) standards. The CDASH standards identify those elements that should be captured on a Case Report Form (CRF). The forms serve only as templates, and must be edited to meet the study data collection needs as described in the protocol.

Link

https://ictr.wisc.edu/CaseReptTempt

Trefwoorden

Versies (2)
  1. 23-07-16 23-07-16 -
  2. 17-11-16 17-11-16 -
Geüploaded op

17 november 2016

DOI

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Licentie

Creative Commons BY-NC 3.0
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Physical Examination: CRF Wisconsin Madison

Engels

Physical Examination: CRF Wisconsin Madison

1 Formulieren  
Header
Beschrijving

Header

PI Name
Beschrijving

PI Name

Datatype

text

Alias
UMLS CUI [1,1]
C0027365
UMLS CUI [1,2]
C1521895
Protocol or IRB Number
Beschrijving

Protocol or IRB Number

Datatype

integer

Alias
UMLS CUI [1]
C2348563
Protocol Short Title
Beschrijving

Protocol Short Title

Datatype

text

Alias
UMLS CUI [1,1]
C2348563
UMLS CUI [1,2]
C1705824
Subject Initials
Beschrijving

Subject Initials

Datatype

text

Alias
UMLS CUI [1]
C2986440
Subject ID
Beschrijving

Subject ID

Datatype

text

Alias
UMLS CUI [1]
C2348585
Exam Date
Beschrijving

Exam Date

Datatype

date

Alias
UMLS CUI [1]
C2826643
Physical Examination
Beschrijving

Physical Examination

Time
Beschrijving

Time

Datatype

time

Alias
UMLS CUI [1]
C0040223
Physical Examination not performed
Beschrijving

Physical Examination not performed

Datatype

boolean

Alias
UMLS CUI [1,1]
C0031809
UMLS CUI [1,2]
C0445106
Visit Number
Beschrijving

Visit Number

Datatype

text

Alias
UMLS CUI [1]
C1549755
Body System
Beschrijving

Body System

Body system to be examined
Beschrijving

Body System

Datatype

text

Alias
UMLS CUI [1]
C0460002
Finding
Beschrijving

Finding

Datatype

text

Alias
UMLS CUI [1]
C0243095
Comments (required if Abnormal)
Beschrijving

Comments

Datatype

text

Alias
UMLS CUI [1]
C0947611
Clinically Significant
Beschrijving

Clinically Significant

Datatype

boolean

Alias
UMLS CUI [1]
C2826293
Other
Beschrijving

Other

Other (specify in Comments)
Beschrijving

Other

Datatype

text

Alias
UMLS CUI [1]
C0205394
Finding
Beschrijving

Finding

Datatype

text

Alias
UMLS CUI [1]
C0243095
Comments (required if Abnormal)
Beschrijving

Comments

Datatype

text

Alias
UMLS CUI [1]
C0947611
Clinically Significant
Beschrijving

Clinically Significant

Datatype

boolean

Alias
UMLS CUI [1]
C2826293
Additional notes
Beschrijving

Additional notes

Datatype

text

Alias
UMLS CUI [1]
C0947611
Physical Examination performed by
Beschrijving

Physical Examination performed by

Datatype

text

Alias
UMLS CUI [1,1]
C0031809
UMLS CUI [1,2]
C1550369
Principal Investigator Signature
Beschrijving

Principal Investigator Signature

Datatype

text

Alias
UMLS CUI [1,1]
C1519316
UMLS CUI [1,2]
C1521895
Date
Beschrijving

Date

Datatype

date

Alias
UMLS CUI [1]
C0011008
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Similar models

Physical Examination: CRF Wisconsin Madison

1 Formulieren
Name
Type
Description | Question | Decode (Coded Value)
Datatype
Alias
Item Group
Header
PI Name
Item
PI Name
text
C0027365 (UMLS CUI [1,1])
C1521895 (UMLS CUI [1,2])
Protocol or IRB Number
Item
Protocol or IRB Number
integer
C2348563 (UMLS CUI [1])
Protocol Short Title
Item
Protocol Short Title
text
C2348563 (UMLS CUI [1,1])
C1705824 (UMLS CUI [1,2])
Subject Initials
Item
Subject Initials
text
C2986440 (UMLS CUI [1])
Subject ID
Item
Subject ID
text
C2348585 (UMLS CUI [1])
Exam Date
Item
Exam Date
date
C2826643 (UMLS CUI [1])
Item Group
Physical Examination
Time
Item
Time
time
C0040223 (UMLS CUI [1])
Physical Examination not performed
Item
Physical Examination not performed
boolean
C0031809 (UMLS CUI [1,1])
C0445106 (UMLS CUI [1,2])
Item
Visit Number
text
C1549755 (UMLS CUI [1])
Visit Number
Code List
Visit Number
CL Item
Visit # (1)
CL Item
Visit # (2)
CL Item
Visit # (3)
CL Item
Visit # (4)
CL Item
Visit # (5)
CL Item
Visit # (6)
Item Group
Body System
Body System
Item
Body system to be examined
text
C0460002 (UMLS CUI [1])
Item
Finding
text
C0243095 (UMLS CUI [1])
Finding
Code List
Finding
CL Item
Normal (1)
CL Item
Abnormal (2)
CL Item
Not examined (3)
Comments
Item
Comments (required if Abnormal)
text
C0947611 (UMLS CUI [1])
Clinically Significant
Item
Clinically Significant
boolean
C2826293 (UMLS CUI [1])
Item Group
Other
Other
Item
Other (specify in Comments)
text
C0205394 (UMLS CUI [1])
Item
Finding
text
C0243095 (UMLS CUI [1])
Finding
Code List
Finding
CL Item
Normal (1)
CL Item
Abnormal (2)
CL Item
Not examined (3)
Comments
Item
Comments (required if Abnormal)
text
C0947611 (UMLS CUI [1])
Clinically Significant
Item
Clinically Significant
boolean
C2826293 (UMLS CUI [1])
Additional notes
Item
Additional notes
text
C0947611 (UMLS CUI [1])
Physical Examination performed by
Item
Physical Examination performed by
text
C0031809 (UMLS CUI [1,1])
C1550369 (UMLS CUI [1,2])
Principal Investigator Signature
Item
Principal Investigator Signature
text
C1519316 (UMLS CUI [1,1])
C1521895 (UMLS CUI [1,2])
Date
Item
Date
date
C0011008 (UMLS CUI [1])
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