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ID
15149
Description
This measure uses existing medical records to obtain information about colorectal exams and procedures. ODM derived from: https://cde.nlm.nih.gov Primary source: https://www.phenxtoolkit.org/ Recent publication: Hendershot, T., Pan, H., Haines, J., Harlan, W.R., Marazita, M.L., McCarty, C.A., Ramos, E.M., and Hamilton, C.M. (2015) Using the PhenX toolkit to add standard measures to a study. Curr. Protoc. Hum. Genet. 86:1.21.1-1.21.17. doi: 10.1002/0471142905.hg0121s86 Permission to publish granted by Carol M. Hamilton.
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Keywords
Versions (2)
- 9/27/17 9/27/17 -
- 9/20/21 9/20/21 -
Uploaded on
September 27, 2017
DOI
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Creative Commons BY-NC 3.0
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Colorectal Procedures and Outcomes (Medical Record Review) Protocol PhenX Toolkit
Colorectal Procedures and Outcomes (Medical Record Review) Protocol PhenX Toolkit
Similar models
Colorectal Procedures and Outcomes (Medical Record Review) Protocol PhenX Toolkit
Name
Type
Description | Question | Decode (Coded Value)
Data type
Alias
Item Group
PhenX - colorectal procedures and outcomes protocol
C3171950 (UMLS CUI-1)
date abstracted
Item
Date Abstracted
date
C3259344 (UMLS CUI [1])
abstractor ID Number
Item
Abstractor ID Number
text
C3259345 (UMLS CUI [1])
nosologist ID number
Item
Nosologist ID Number
text
C3259347 (UMLS CUI [1])
CTR ID number
Item
CTR ID Number
text
C3261211 (UMLS CUI [1])
study year
Item
Study Year
integer
C3258203 (UMLS CUI [1])
CL Item
Initial abstract (Initial abstract )
CL Item
Re-abstract for QA (Re-abstract for QA)
multiple primary cancer number
Item
Multiple Primary Cancer Number
integer
C0865021 (UMLS CUI [1])
form receipted into SMS
Item
Form Receipted into SMS
boolean
C3259351 (UMLS CUI [1])
manual review completed
Item
Manual Review Completed
boolean
C3259354 (UMLS CUI [1])
CL Item
Completed (Completed )
CL Item
None required (None required)
CL Item
Attempted (Attempted )
CL Item
None required (None required)
CL Item
Interim complete (ICM) (Interim complete (ICM) )
CL Item
Final complete (FCM) (Final complete (FCM) )
CL Item
Final incomplete (FIG) (Final incomplete (FIG))
CL Item
Yes (Yes)
CL Item
No, physician report (No, physician report )
CL Item
No, participant self-report (No, participant self-report)
Item
Reason for initial visit for clinical assessment
text
C1704447 (UMLS CUI [1,1])
C0205265 (UMLS CUI [1,2])
C0205265 (UMLS CUI [1,2])
CL Item
Symptomatic (Symptomatic )
CL Item
Follow-up of positive PLCO screen (Follow-up of positive PLCO screen)
CL Item
Other (Other)
initial visit reason other
Item
Specify Other Reason for Initial Visit for Clinical Assessment
text
C1704447 (UMLS CUI [1,1])
C0205265 (UMLS CUI [1,2])
C0205394 (UMLS CUI [1,3])
C0205265 (UMLS CUI [1,2])
C0205394 (UMLS CUI [1,3])
Item
Sigmoidoscopy or Colonoscopy
text
C0037075 (UMLS CUI [1])
C0009378 (UMLS CUI [2])
C0009378 (UMLS CUI [2])
CL Item
No (No)
C1298908 (UMLS CUI-1)
CL Item
Yes (Yes)
C1705108 (UMLS CUI-1)
CL Item
Unknown (Unknown)
C0439673 (UMLS CUI-1)
date of trauma or procedure
Item
Date of trauma or procedure
date
C2584899 (UMLS CUI [1])
CL Item
No (No)
C1298908 (UMLS CUI-1)
CL Item
Yes (Yes)
C1705108 (UMLS CUI-1)
CL Item
Not available (Not available)
C1548671 (UMLS CUI-1)
CL Item
Inadequate (Inadequate )
CL Item
Adequate (Adequate )
CL Item
Not available (Not available)
CL Item
None (None)
CL Item
One (One)
CL Item
Multiple (Multiple)
CL Item
Sigmoidoscopy (Sigmoidoscopy )
CL Item
Colonoscopy (Colonoscopy )
CL Item
Endoscopy, NOS (Endoscopy, NOS)
Item
Adenomas on Sigmoidoscopy or Colonoscopy
text
C0009378 (UMLS CUI [1,1])
C0001430 (UMLS CUI [1,2])
C0001430 (UMLS CUI [1,2])
CL Item
No (No)
C1298908 (UMLS CUI-1)
CL Item
Yes (Yes)
C1705108 (UMLS CUI-1)
CL Item
Not available (Not available)
C1548671 (UMLS CUI-1)
multiple polyps
Item
Multiple polyps in specimen jar
boolean
C0334108 (UMLS CUI [1])
CL Item
Sigmoidoscopy (Sigmoidoscopy )
CL Item
Colonoscopy (Colonoscopy )
CL Item
Endoscopy, NOS (Endoscopy, NOS)
CL Item
Cecum (Cecum )
CL Item
Ascending colon (Ascending colon )
CL Item
Hepatic flexure (Hepatic flexure )
CL Item
Transverse colon (Transverse colon )
CL Item
Splenic flexure (Splenic flexure )
CL Item
Descending colon (Descending colon )
CL Item
Sigmoid colon (Sigmoid colon )
CL Item
Rectum (Rectum )
CL Item
Appendix (Appendix )
CL Item
Not available (Not available)
adenoma distance
Item
LOCATION - Distance in cm
integer
C3260292 (UMLS CUI [1])
adenoma dimension
Item
SIZE - Longest dimension in cm
integer
C3260294 (UMLS CUI [1])
CL Item
Diminutive (Diminutive )
CL Item
Small (Small)
CL Item
Large (Large)
CL Item
Not available (Not available)
CL Item
Tubular adenoma (Tubular adenoma )
CL Item
Tubular villous adenoma (Tubular villous adenoma)
CL Item
Villous adenoma (Villous adenoma)
CL Item
Adenoma (NOS) (Adenoma (NOS))
CL Item
None (None )
CL Item
Mild (low grade) (Mild (low grade) )
CL Item
Moderate (low grade) (Moderate (low grade) )
CL Item
Severe (high grade) (Severe (high grade) )
CL Item
Not available (Not available)
non-advanced adenomas
Item
Number of Non-advanced adenomas
integer
C3257924 (UMLS CUI [1])
advanced adenomas
Item
Number of Advanced adenomas
integer
C3260303 (UMLS CUI [1])
exact number adenomas determined
Item
Can exact number of adenomas be determined?
boolean
C3260305 (UMLS CUI [1])
Item
Other Diagnostic/Staging Procedures
text
C3257959 (UMLS CUI [1])
CL Item
No (No)
C1298908 (UMLS CUI-1)
CL Item
Yes (Yes)
C1705108 (UMLS CUI-1)
CL Item
Unknown (Unknown)
C0439673 (UMLS CUI-1)
CL Item
Abdominal flat plate (plain film) (Abdominal flat plate (plain film) )
CL Item
Barium enema radiograph (Barium enema radiograph )
CL Item
Biopsy (Biopsy)
CL Item
Chest radiograph (Chest radiograph )
CL Item
Clinical evaluation (Clinical evaluation)
CL Item
CT scan - abdominal (CT scan - abdominal )
CL Item
CT scan - other (CT scan - other )
CL Item
CT scan - pelvic (CT scan - pelvic)
CL Item
Cystoscopy (Cystoscopy)
CL Item
DRE (DRE)
CL Item
Intravenous pyelography (IVP)/excretory urography (Intravenous pyelography (IVP)/excretory urography)
CL Item
MRI scan - abdominal (MRI scan - abdominal )
CL Item
MRI scan - other (MRI scan - other )
CL Item
MRI scan - pelvic (MRI scan - pelvic )
CL Item
PreoperatIve carcinoembryonic antigen (CEA) (PreoperatIve carcinoembryonic antigen (CEA) )
CL Item
Stool occult blood (Stool occult blood )
CL Item
Record review (Record review)
CL Item
Resection (Resection)
CL Item
Abdominal ultrasound (Abdominal ultrasound )
CL Item
CT scan - abdomen and pelvis combined (CT scan - abdomen and pelvis combined )
CL Item
Hemicolectomy (Hemicolectomy)
CL Item
Laparoscopy (Laparoscopy)
CL Item
Laparotomy (Laparotomy)
CL Item
Lymphadenectomy/Lymph node sampling (Lymphadenectomy/Lymph node sampling)
CL Item
Other radiograph (Other radiograph )
CL Item
Ultrasound (Ultrasound)
CL Item
Upper GI evaluation – endoscopic/radiographic (Upper GI evaluation – endoscopic/radiographic)
CL Item
Other (Other)
other biopsy
Item
Other biopsy [PhenX]
text
C3257956 (UMLS CUI [1])
other CT scan
Item
Other CT scan [PhenX]
text
C0177779 (UMLS CUI [1])
other MRI scan
Item
Other MRI scan [PhenX]
text
C3257971 (UMLS CUI [1])
other resection
Item
Other resection [PhenX]
text
C3257977 (UMLS CUI [1])
other radiograph
Item
Other radiograph [PhenX]
text
C3257974 (UMLS CUI [1])
other ultrasound
Item
Other ultrasound [PhenX]
text
C3257986 (UMLS CUI [1])
other diagnostic staging procedure
Item
Type of procedure - specify
text
C3257959 (UMLS CUI [1])
diagnostic procedures supplement form completed
Item
Diagnostic/Staging procedures supplement form completed
boolean
C3260311 (UMLS CUI [1])
Item
Medical Complications of Diagnostic Evaluation and Staging
text
C0221791 (UMLS CUI [1])
CL Item
No (No)
C1298908 (UMLS CUI-1)
CL Item
Yes (Yes)
C1705108 (UMLS CUI-1)
CL Item
Unknown (Unknown)
C0439673 (UMLS CUI-1)
CL Item
Stroke (CVA) or TIA (Stroke (CVA) or TIA)
CL Item
Infection (Infection)
CL Item
Fever requiring antibiotics (Fever requiring antibiotics )
CL Item
Perforation (Perforation)
CL Item
Hemorrhage (Hemorrhage)
CL Item
Respiratory arrest (Respiratory arrest )
CL Item
Cardiac arrest (Cardiac arrest )
CL Item
Hospitalization (Hospitalization)
CL Item
Pulmonary embolus/emboli (Pulmonary embolus/emboli )
CL Item
Myocardial infarction (Myocardial infarction )
CL Item
Cardiac arrhythmia (Cardiac arrhythmia)
CL Item
Cerebral vascular accident (CVA)/Stroke (Cerebral vascular accident (CVA)/Stroke )
CL Item
Blood loss requiring transfusion (Blood loss requiring transfusion )
CL Item
Deep vein thrombosis (Deep vein thrombosis)
CL Item
Acute/chronic respiratory failure (Acute/chronic respiratory failure )
CL Item
Hypotension (Hypotension)
CL Item
Congestive heart failure (CHF) (Congestive heart failure (CHF))
CL Item
Wound dehiscence (Wound dehiscence )
CL Item
Hypokalemia (Hypokalemia)
CL Item
Diarrhea (Diarrhea)
CL Item
Small bowel obstruction/partial or complete (Small bowel obstruction/partial or complete)
CL Item
Ileus (Ileus)
CL Item
Rectal damage (Rectal damage)
CL Item
Blood In stool (Blood In stool)
infection
Item
Type of complication - infection - specify
text
C0009450 (UMLS CUI [1])
date of complication
Item
Date of complication
date
C0011008 (UMLS CUI [1,1])
C0009566 (UMLS CUI [1,2])
C0009566 (UMLS CUI [1,2])
Item
Result of Diagnostic Evaluation for Colorectal Cancer
text
C3260317 (UMLS CUI [1])
Code List
Result of Diagnostic Evaluation for Colorectal Cancer
CL Item
No malignancy (No malignancy )
CL Item
No malignancy and no diagnostic/staging procedures performed (No malignancy and no diagnostic/staging procedures performed )
CL Item
Colorectal malignancy confirmed histologically (exclude carcinoma in situ) (Colorectal malignancy confirmed histologically (exclude carcinoma in situ) )
CL Item
Colorectal malignancy confirmed cytologically (Colorectal malignancy confirmed cytologically )
CL Item
Colorectal malignancy diagnosed by clinical examination only (Colorectal malignancy diagnosed by clinical examination only )
CL Item
Other malignancy confirmed histologicaly or cytologically (Other malignancy confirmed histologicaly or cytologically )
CL Item
No information available (No information available)
other cancer diagnosis
Item
Other Cancer Diagnosis
boolean
C3257957 (UMLS CUI [1])
diagnosis ICD code
Item
Diagnosis ICD code
text
C2598420 (UMLS CUI [1])
description of colorectal carcinoma
Item
Description of Colorectal Carcinoma
text
C0009402 (UMLS CUI [1])
Item
Procedure for primary diagnosis of colorectal carcinoma [PhenX]
text
C0332137 (UMLS CUI [1,1])
C0087111 (UMLS CUI [1,2])
C0087111 (UMLS CUI [1,2])
Code List
Procedure for primary diagnosis of colorectal carcinoma [PhenX]
CL Item
Sigmoidoscopy (Sigmoidoscopy)
CL Item
Colonoscopy (Colonoscopy)
CL Item
Polypectomy (Polypectomy)
CL Item
Surgical resection (Surgical resection )
CL Item
Local transanal or other resection (Local transanal or other resection)
CL Item
Endoscopy (Endoscopy)
CL Item
Exophytic (Exophytic)
CL Item
Endophytic (Endophytic)
CL Item
Annular (Annular)
CL Item
Diffusely infiltrative (Diffusely infiltrative )
CL Item
Not available (Not available)
date first cancer diagnosis
Item
Date first Dx Cancer
date
C4019001 (UMLS CUI [1,1])
C0006826 (UMLS CUI [1,2])
C0006826 (UMLS CUI [1,2])
primary colorectal cancer diagnosis
Item
Verbatim Description of Primary Colorectal Cancer Diagnosis
text
C3258300 (UMLS CUI [1])
ICDO2 cancer - topography
Item
ICD-O-2 Cancer Classification: Topography
text
C3260324 (UMLS CUI [1])
ICDO2 cancer - morphology
Item
ICD-O-2 Cancer Classification: Morphology
text
C3260326 (UMLS CUI [1])
Item
ICD-O-2 Cancer Classification: Behavior
integer
C3260328 (UMLS CUI [1])
CL Item
1 (1)
CL Item
3 (2)
CL Item
9 (3)
CL Item
1 (1)
CL Item
2 (2)
CL Item
3 (3)
CL Item
4 (4)
CL Item
5 (5)
CL Item
6 (6)
CL Item
7 (7)
CL Item
9 (8)
Item
Photocopy of Report Confirming Primary Colorectal Cancer
text
C3260332 (UMLS CUI [1])
CL Item
Pathology/Histopathology (ATTACH COPY) (Pathology/Histopathology (ATTACH COPY) )
CL Item
Cytology/Cytopathology (ATTACH COPY) (Cytology/Cytopathology (ATTACH COPY))
CL Item
Not available (Not available)
Item
Histopathologic Type for Primary Colorectal Cancer
text
C3260333 (UMLS CUI [1])
CL Item
Adenocarcinoma (Adenocarcinoma)
CL Item
Mucinous (colloid) adenocarcinoma (Mucinous (colloid) adenocarcinoma )
CL Item
Signet ring cell carcinoma (Signet ring cell carcinoma)
CL Item
Squamous cell (epidermoid) carcinoma (Squamous cell (epidermoid) carcinoma)
CL Item
Adenosquamous carcinoma (Adenosquamous carcinoma )
CL Item
Undifferentiated carcinoma (Undifferentiated carcinoma )
CL Item
Carcinoma (Carcinoma)
CL Item
Other (Other)
CL Item
Unknown (Unknown)
other histopathologic type
Item
Specify Other Histopathologic Type for Primary Colorectal Cancer
text
C3260335 (UMLS CUI [1])
Item
Histopathologic Grade for Primary Colorectal Cancer
text
C3260336 (UMLS CUI [1])
CL Item
Grade cannot be assessed (GX) (Grade cannot be assessed (GX))
CL Item
Well differentiated (G1) (Well differentiated (G1))
CL Item
Moderately differentiated (G2) (Moderately differentiated (G2) )
CL Item
Poorly differentiated (G3) (Poorly differentiated (G3))
CL Item
Undifferentiated (G4) (Undifferentiated (G4) )
CL Item
Unknown (Unknown)
Item
If TNM Staging performed, what AJCC Cancer Staging Manual did you use?
text
C3260339 (UMLS CUI [1])
Code List
If TNM Staging performed, what AJCC Cancer Staging Manual did you use?
CL Item
4th edition (4th edition )
CL Item
5th edition (5th edition)
TNM Clinical Staging
Item
TNM Clinical Staging
boolean
C3258246 (UMLS CUI [1])
CL Item
TX (TX)
CL Item
T0 (T0)
CL Item
T1 (T1)
CL Item
T2 (T2)
CL Item
T3 (T3)
CL Item
T4 (T4)
CL Item
Not available (Not available)
CL Item
NX (NX)
CL Item
N0 (N0)
CL Item
N1 (N1)
CL Item
N2 (N2)
CL Item
N3 (N3)
CL Item
Not available (Not available)
CL Item
MX (MX)
CL Item
M0 (M0)
CL Item
M1 (M1)
CL Item
Not available (Not available)
TNM path staging
Item
TNM Pathologic Staging
boolean
C3260344 (UMLS CUI [1])
CL Item
TX (TX)
CL Item
T0 (T0)
CL Item
T1 (T1)
CL Item
T2 (T2)
CL Item
T3 (T3)
CL Item
T4 (T4)
CL Item
Not available (Not available)
CL Item
NX (NX)
CL Item
N0 (N0)
CL Item
N1 (N1)
CL Item
N2 (N2)
CL Item
N3 (N3)
CL Item
Not available (Not available)
CL Item
MX (MX)
CL Item
M0 (M0)
CL Item
M1 (M1)
CL Item
Not available (Not available)
record stage
Item
Record Stage
boolean
C3258105 (UMLS CUI [1])
CL Item
I (I)
CL Item
II (II)
CL Item
III (III)
CL Item
IV (IV)
CL Item
A (A)
CL Item
B (B)
CL Item
C (C)
CL Item
Not available (Not available)
CL Item
A (A)
CL Item
B1 (B1)
CL Item
B2 (B2)
CL Item
C1 (C1)
CL Item
C2 (C2)
CL Item
D (D)
CL Item
Not available (Not available)
CL Item
Localized (Localized)
CL Item
Regional (Regional)
CL Item
Distant (Distant)
CL Item
Not available (Not available)
date of diagnosis
Item
Date of diagnosis?
date
C2316983 (UMLS CUI [1])
diagnosing provider
Item
Have you been diagnosed with Crohn's disease or another inflammatory bowel disorder? Explanation: (diagnosis if known, date of diagnosis, doctor who made the diagnosis)
text
C3260207 (UMLS CUI [1])
address facility
Item
Address Facility
text
C3176337 (UMLS CUI [1])
phone number
Item
Phone number
text
C1515258 (UMLS CUI [1])
medical record number
Item
Medical record number
text
C1301894 (UMLS CUI [1])
name hospital
Item
Hospitalized at
text
C0019994 (UMLS CUI [1])
service comment
Item
Service comment
text
C0485795 (UMLS CUI [1])
service comment
Item
Service comment
text
C0485795 (UMLS CUI [1])