ID

10342

Description

Re-Admission/Hospitalization Form (ADM) Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=FF1A99BE-38AD-3F09-E034-0003BA3F9857

Link

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=FF1A99BE-38AD-3F09-E034-0003BA3F9857

Keywords

Versions (2)
  1. 9/19/12 9/19/12 -
  2. 5/28/15 5/28/15 -
Uploaded on

May 28, 2015

DOI

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License

Creative Commons BY-NC 3.0 Legacy
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Re-Admission/Hospitalization Form (ADM)

English

No Instruction available.

1 forms  
  1. StudyEvent: Re-Admission/Hospitalization Form (ADM)
    1. No Instruction available.
Header Module
Description

Header Module

Segment
Description

Segment

Data type

text

Date of Admission
Description

HospitalAdmissionDate

Data type

date

Alias
NCI Thesaurus ValueDomain
C25164
UMLS 2011AA ValueDomain
C0011008
NCI Thesaurus ObjectClass
C16696
UMLS 2011AA ObjectClass
C0019994
NCI Thesaurus Property
C25385
UMLS 2011AA Property
C0809949
Date of discharge
Description

HospitalDischargeDate

Data type

date

Alias
NCI Thesaurus ValueDomain
C25164
UMLS 2011AA ValueDomain
C0011008
NCI Thesaurus ObjectClass
C16696
UMLS 2011AA ObjectClass
C0019994
NCI Metathesaurus Property
C0012621
Patient discharge status
Description

PatientVitalStatus

Data type

text

Alias
NCI Thesaurus ObjectClass
C16960
UMLS 2011AA ObjectClass
C0030705
NCI Thesaurus ValueDomain
C18003
UMLS 2011AA ValueDomain
C0442732
NCI Thesaurus ValueDomain-2
C25688
UMLS 2011AA ValueDomain-2
C0449438
NCI Thesaurus Property
C25717
UMLS 2011AA Property
C1148433
Record Secondary Discharge Diagnoses
Description

Record Secondary Discharge Diagnoses

Record PRIMARY discharge diagnosis
Description

RecordPRIMARYdischargediagnosis

Data type

text

Specify organ
Description

Specifyorgan

Data type

text

Specify other
Description

AssessmentMethodSpecify

Data type

text

Alias
NCI Thesaurus ValueDomain
C25685
UMLS 2011AA ValueDomain
C1521902
NCI Thesaurus ObjectClass
C20989
UMLS 2011AA ObjectClass
C0031809
NCI Thesaurus Property
C16847
UMLS 2011AA Property
C0449851
GVHD
Description

GVHD

Data type

text

Relapse
Description

Relapse

Data type

text

Graft Failure
Description

GraftFailure

Data type

text

Infection
Description

Infection

Data type

text

Fever
Description

Fever

Data type

text

Seizure
Description

Seizure

Data type

text

Bleeding/Hemorrhage
Description

Bleeding/Hemorrhage

Data type

text

Diarrhea
Description

Diarrhea

Data type

text

Nausea/Vomiting
Description

Nausea/Vomiting

Data type

text

Organ Failure
Description

OrganFailure

Data type

text

Specify organ
Description

Specifyorgans

Data type

text

Trauma
Description

Trauma

Data type

text

Pyschiatric
Description

Pyschiatric

Data type

text

Secondary Malignancy
Description

SecondaryMalignancy

Data type

text

Other
Description

Other

Data type

text

Specify other
Description

DeathContributingSymptomSpecify

Data type

text

Alias
NCI Thesaurus ValueDomain
C25685
UMLS 2011AA ValueDomain
C1521902
NCI Thesaurus ObjectClass
C28554
UMLS 2011AA ObjectClass
C0011065
NCI Thesaurus Property
C4876
UMLS 2011AA Property
C1457887
NCI Metathesaurus Property
CL317017
Record re-admission institution
Description

Recordre-admissioninstitution

Data type

text

Comment
Description

ResearchCommentsText

Data type

text

Alias
NCI Thesaurus ValueDomain
C25704
UMLS 2011AA ValueDomain
C1527021
NCI Thesaurus ObjectClass
C15319
NCI Thesaurus Property
C25393
UMLS 2011AA Property
C0282411
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Similar models

No Instruction available.

1 forms
  1. StudyEvent: Re-Admission/Hospitalization Form (ADM)
    1. No Instruction available.
Name
Type
Description | Question | Decode (Coded Value)
Data type
Alias
Item Group
Header Module
Segment
Item
Segment
text
HospitalAdmissionDate
Item
Date of Admission
date
C25164 (NCI Thesaurus ValueDomain)
C0011008 (UMLS 2011AA ValueDomain)
C16696 (NCI Thesaurus ObjectClass)
C0019994 (UMLS 2011AA ObjectClass)
C25385 (NCI Thesaurus Property)
C0809949 (UMLS 2011AA Property)
HospitalDischargeDate
Item
Date of discharge
date
C25164 (NCI Thesaurus ValueDomain)
C0011008 (UMLS 2011AA ValueDomain)
C16696 (NCI Thesaurus ObjectClass)
C0019994 (UMLS 2011AA ObjectClass)
C0012621 (NCI Metathesaurus Property)
Item
Patient discharge status
text
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C18003 (NCI Thesaurus ValueDomain)
C0442732 (UMLS 2011AA ValueDomain)
C25688 (NCI Thesaurus ValueDomain-2)
C0449438 (UMLS 2011AA ValueDomain-2)
C25717 (NCI Thesaurus Property)
C1148433 (UMLS 2011AA Property)
CL.1
Code List
Patient discharge status
CL Item
Alive (Alive)
CL Item
Dead (Dead)
Item Group
Record Secondary Discharge Diagnoses
Item
Record PRIMARY discharge diagnosis
text
CL.2
Code List
Record PRIMARY discharge diagnosis
CL Item
GVHD (GVHD)
CL Item
Relapse (Relapse)
CL Item
Graft Failure (Graft Failure)
CL Item
Infection (Infection)
CL Item
Fungal Infection (Fungal Infection)
CL Item
Non-Fungal Infection (Non-Fungal Infection)
CL Item
Fever (Fever)
CL Item
Seizure (Seizure)
CL Item
Bleeding/Hemorrhage (Bleeding/Hemorrhage)
CL Item
Diarrhea (Diarrhea)
CL Item
Nausea/Vomiting (Nausea/Vomiting)
CL Item
Organ Failure (specify organ) (Organ Failure (specify organ))
CL Item
Trauma (Trauma)
CL Item
Pyschiatric (Pyschiatric)
CL Item
Secondary Malignancy (Secondary Malignancy)
CL Item
Transplant (Transplant)
CL Item
Other (specify) (Other (specify))
Specifyorgan
Item
Specify organ
text
AssessmentMethodSpecify
Item
Specify other
text
C25685 (NCI Thesaurus ValueDomain)
C1521902 (UMLS 2011AA ValueDomain)
C20989 (NCI Thesaurus ObjectClass)
C0031809 (UMLS 2011AA ObjectClass)
C16847 (NCI Thesaurus Property)
C0449851 (UMLS 2011AA Property)
Item
GVHD
text
CL.3
Code List
GVHD
CL Item
Contributory (Contributory)
CL Item
Noncontributory (Noncontributory)
Item
Relapse
text
CL.4
Code List
Relapse
CL Item
Contributory (Contributory)
CL Item
Noncontributory (Noncontributory)
Item
Graft Failure
text
CL.5
Code List
Graft Failure
CL Item
Contributory (Contributory)
CL Item
Noncontributory (Noncontributory)
Item
Infection
text
CL.6
Code List
Infection
CL Item
Contributory (Contributory)
CL Item
Noncontributory (Noncontributory)
Item
Fever
text
CL.7
Code List
Fever
CL Item
Contributory (Contributory)
CL Item
Noncontributory (Noncontributory)
Item
Seizure
text
CL.8
Code List
Seizure
CL Item
Contributory (Contributory)
CL Item
Noncontributory (Noncontributory)
Item
Bleeding/Hemorrhage
text
CL.9
Code List
Bleeding/Hemorrhage
CL Item
Contributory (Contributory)
CL Item
Noncontributory (Noncontributory)
Item
Diarrhea
text
CL.10
Code List
Diarrhea
CL Item
Contributory (Contributory)
CL Item
Noncontributory (Noncontributory)
Item
Nausea/Vomiting
text
CL.11
Code List
Nausea/Vomiting
CL Item
Contributory (Contributory)
CL Item
Noncontributory (Noncontributory)
Item
Organ Failure
text
CL.12
Code List
Organ Failure
CL Item
Contributory (Contributory)
CL Item
Noncontributory (Noncontributory)
Specifyorgans
Item
Specify organ
text
Item
Trauma
text
CL.13
Code List
Trauma
CL Item
Contributory (Contributory)
CL Item
Noncontributory (Noncontributory)
Item
Pyschiatric
text
CL.14
Code List
Pyschiatric
CL Item
Contributory (Contributory)
CL Item
Noncontributory (Noncontributory)
Item
Secondary Malignancy
text
CL.15
Code List
Secondary Malignancy
CL Item
Contributory (Contributory)
CL Item
Noncontributory (Noncontributory)
Item
Other
text
CL.16
Code List
Other
CL Item
Contributory (Contributory)
CL Item
Noncontributory (Noncontributory)
DeathContributingSymptomSpecify
Item
Specify other
text
C25685 (NCI Thesaurus ValueDomain)
C1521902 (UMLS 2011AA ValueDomain)
C28554 (NCI Thesaurus ObjectClass)
C0011065 (UMLS 2011AA ObjectClass)
C4876 (NCI Thesaurus Property)
C1457887 (UMLS 2011AA Property)
CL317017 (NCI Metathesaurus Property)
Item
Record re-admission institution
text
CL.17
Code List
Record re-admission institution
CL Item
Original Transplant Center (Original Transplant Center)
CL Item
Other Transplant Center (Other Transplant Center)
CL Item
Other Hospital (Other Hospital)
ResearchCommentsText
Item
Comment
text
C25704 (NCI Thesaurus ValueDomain)
C1527021 (UMLS 2011AA ValueDomain)
C15319 (NCI Thesaurus ObjectClass)
C25393 (NCI Thesaurus Property)
C0282411 (UMLS 2011AA Property)
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