Engelsk

Treatment Form Day 1 to 4

1 Formulär  
Patient Identification
Beskrivning

Patient Identification

Hyper-PEI-UPN
Beskrivning

Hyper-PEI-UPN

Datatyp

text

Date
Beskrivning

Date

Datatyp

date

Alias
UMLS CUI [1]
C0011008
Body weight
Beskrivning

Weight

Datatyp

float

Måttenheter
  • kg
Alias
UMLS CUI [1]
C0005910
kg
Height
Beskrivning

Height

Datatyp

float

Måttenheter
  • cm
Alias
UMLS CUI [1]
C0005890
cm
BSA
Beskrivning

Body surface

Datatyp

float

Måttenheter
  • m²
Alias
UMLS CUI [1]
C0005902
m²
Technical Specifications
Beskrivning

Technical Specifications

Maximum Output
Beskrivning

Maximum Output

Datatyp

text

Måttenheter
  • Watt
Alias
UMLS CUI [1,1]
C0020548
UMLS CUI [1,2]
C1709366
Watt
Frequency
Beskrivning

Frequency

Datatyp

text

Måttenheter
  • MHz
Alias
UMLS CUI [1,1]
C0020548
UMLS CUI [1,2]
C2826655
MHz
Focus
Beskrivning

Focus

Datatyp

text

Process of Hyperthermia
Beskrivning

Process of Hyperthermia

Organ
Beskrivning

Cave: complete AE/SAE Form if need be

Datatyp

text

Alias
UMLS CUI [1]
C0807185
Tumor Probe
Beskrivning

Tumor Probe

Datatyp

text

Alias
UMLS CUI [1]
C3882401
Urinary Bladder
Beskrivning

Bladder

Datatyp

text

Alias
UMLS CUI [1]
C0005682
Rectum
Beskrivning

Rectum

Datatyp

text

Alias
UMLS CUI [1]
C0034896
Vagina
Beskrivning

Vagina

Datatyp

text

Alias
UMLS CUI [1]
C0042232
Skin
Beskrivning

Note any abnormality

Datatyp

text

Alias
UMLS CUI [1]
C1123023
Vital signs
Beskrivning

Vital signs

Pulse
Beskrivning

Pulse Rate

Datatyp

integer

Måttenheter
  • beats/min
Alias
UMLS CUI [1]
C0232117
Oxygen saturation (SaO2):
Beskrivning

Oxygen saturation

Datatyp

text

Alias
UMLS CUI [1]
C0523807
Blood pressure (RR)
Beskrivning

Blood Pressure

Datatyp

integer

Alias
UMLS CUI [1]
C0005823
Chemotherapy
Beskrivning

Chemotherapy

Cycle Number
Beskrivning

Cycle

Datatyp

integer

Alias
UMLS CUI [1]
C2045829
Day of Treatment
Beskrivning

Day of Treatment

Datatyp

text

Alias
UMLS CUI [1]
C3468389
Total amount of medication given
Beskrivning

Medication

Datatyp

text

Alias
UMLS CUI [1]
C3174092
Total amount of cisplatin administered this reporting period
Beskrivning

40mg/m²

Datatyp

float

Måttenheter
  • mg
Alias
UMLS CUI [1]
C0008838
mg
Total amount of Carboplatin administerd
Beskrivning

400mg/m²

Datatyp

float

Måttenheter
  • mg
Alias
UMLS CUI [1]
C0079083
mg
Total amount of Etoposide administered
Beskrivning

100mg/m²

Datatyp

float

Måttenheter
  • mg
Alias
UMLS CUI [1]
C0015133
mg
Total amount of Mesna-Bolus administered
Beskrivning

600mg/m²

Datatyp

float

Måttenheter
  • mg
Alias
UMLS CUI [1]
C0000294
mg
Total amount of Ifosfamide administered
Beskrivning

1800mg/m²

Datatyp

float

Måttenheter
  • mg
Alias
UMLS CUI [1]
C0020823
mg
Total amount of Cyclophosphamide administered
Beskrivning

600mg/m²

Datatyp

float

Måttenheter
  • mg
Alias
UMLS CUI [1]
C0010583
mg
Total amount of Mesna administered
Beskrivning

1800mg/m²

Datatyp

float

Måttenheter
  • mg
Alias
UMLS CUI [1]
C0000294
mg
Total amount of medication given for sedation
Beskrivning

Sedation

Datatyp

float

Måttenheter
  • mg
Alias
UMLS CUI [1]
C0344106
mg
Any other Medication administered
Beskrivning

Other Medication

Datatyp

text

Alias
UMLS CUI [1]
C0013227
Correctness of information confirmed
Beskrivning

Correctness of information confirmed

Date
Beskrivning

Date

Datatyp

date

Alias
UMLS CUI [1]
C0011008
Treating Physician
Beskrivning

Physician

Datatyp

text

Alias
UMLS CUI [1]
C1710470
Signature
Beskrivning

Responsible Person Signature

Datatyp

text

Alias
UMLS CUI [1]
C1550483
Chemotherapy
Beskrivning

Chemotherapy

Cycle number
Beskrivning

Cycle

Datatyp

integer

Alias
UMLS CUI [1]
C2045829
Day of Treatment
Beskrivning

Day of Treatment

Datatyp

text

Alias
UMLS CUI [1]
C3468389
Total amount of medication administered
Beskrivning

Medication

Datatyp

text

Alias
UMLS CUI [1]
C3174092
Total amount of Etoposide administered
Beskrivning

100mg/m²

Datatyp

float

Måttenheter
  • mg
Alias
UMLS CUI [1]
C0015133
mg
Total amount of Ifosfamide administered
Beskrivning

1800mg/m²

Datatyp

float

Måttenheter
  • mg
Alias
UMLS CUI [1]
C0020823
mg
Total amount of Cyclophosphamide administered
Beskrivning

600mg/m²

Datatyp

float

Måttenheter
  • mg
Alias
UMLS CUI [1]
C0010583
mg
Total amount of Mesna administered
Beskrivning

1800mg/m²

Datatyp

float

Måttenheter
  • mg
Alias
UMLS CUI [1]
C0000294
mg
Any other medication administered
Beskrivning

Other Medication

Datatyp

text

Alias
UMLS CUI [1]
C0013227
Correctness of information confirmed
Beskrivning

Correctness of information confirmed

Date
Beskrivning

Date

Datatyp

date

Alias
UMLS CUI [1]
C0011008
Treating Physician
Beskrivning

Physician

Datatyp

text

Alias
UMLS CUI [1]
C1710470
Signature
Beskrivning

Responsible Person Signature

Datatyp

text

Alias
UMLS CUI [1]
C1550483
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Similar models

Treatment Form Day 1 to 4

1 Formulär
Name
Typ
Description | Question | Decode (Coded Value)
Datatyp
Alias
Item Group
Patient Identification
Hyper-PEI-UPN
Item
Hyper-PEI-UPN
text
Date
Item
Date
date
C0011008 (UMLS CUI [1])
Weight
Item
Body weight
float
C0005910 (UMLS CUI [1])
Height
Item
Height
float
C0005890 (UMLS CUI [1])
Body surface
Item
BSA
float
C0005902 (UMLS CUI [1])
Item Group
Technical Specifications
Maximum Output
Item
Maximum Output
text
C0020548 (UMLS CUI [1,1])
C1709366 (UMLS CUI [1,2])
Frequency
Item
Frequency
text
C0020548 (UMLS CUI [1,1])
C2826655 (UMLS CUI [1,2])
Item
Focus
text
Focus
Code List
Focus
CL Item
_ , Y=_ (X)
Item Group
Process of Hyperthermia
Item
Organ
text
C0807185 (UMLS CUI [1])
Organ
Code List
Organ
CL Item
T max °C , 2=T min °C , 3=T90 °C , 4=T50 °C , 5=T20 °C , 6=CEMT90 min (1)
Item
Tumor Probe
text
C3882401 (UMLS CUI [1])
Tumor Probe
Code List
Tumor Probe
CL Item
T max °C , 2=T min °C , 3=T90 °C , 4=T50 °C , 5=T20 °C , 6=CEMT90 min (1)
Item
Urinary Bladder
text
C0005682 (UMLS CUI [1])
Bladder
Code List
Urinary Bladder
CL Item
T max °C , 2=T min °C , 3=T90 °C , 4=T50 °C , 5=T20 °C , 6=CEMT90 min (1)
Item
Rectum
text
C0034896 (UMLS CUI [1])
Rectum
Code List
Rectum
CL Item
T max °C , 2=T min °C , 3=T90 °C , 4=T50 °C , 5=T20 °C , 6=CEMT90 min (1)
Item
Vagina
text
C0042232 (UMLS CUI [1])
Vagina
Code List
Vagina
CL Item
T max °C , 2=T min °C , 3=T90 °C , 4=T50 °C , 5=T20 °C , 6=CEMT90 min (1)
Item
Skin
text
C1123023 (UMLS CUI [1])
SKIN
Code List
Skin
CL Item
T max °C , 2=T min °C , 3=T90 °C , 4=T50 °C , 5=T20 °C , 6=CEMT90 min (1)
Item Group
Vital signs
Item
Pulse
integer
C0232117 (UMLS CUI [1])
Pulse Rate
Code List
Pulse
CL Item
Start warm up , 2=10min , 3=Start Hyperthermia , 4=15min , 5=30min , 6=45min , 7=60min (1)
Item
Oxygen saturation (SaO2):
text
C0523807 (UMLS CUI [1])
Oxygen saturation
Code List
Oxygen saturation (SaO2):
CL Item
Start warm up , 2=10min , 3=Start Hyperthermia , 4=15min , 5=30min , 6=45min , 7=60min (1)
Item
Blood pressure (RR)
integer
C0005823 (UMLS CUI [1])
Blood Pressure
Code List
Blood pressure (RR)
CL Item
Start warm up , 2=10min , 3=Start Hyperthermia , 4=15min , 5=30min , 6=45min , 7=60min (1)
Item Group
Chemotherapy
Cycle
Item
Cycle Number
integer
C2045829 (UMLS CUI [1])
Item
Day of Treatment
text
C3468389 (UMLS CUI [1])
Day of Treatment
Code List
Day of Treatment
CL Item
Day 1 , 2=Day 4 (1)
Medication
Item
Total amount of medication given
text
C3174092 (UMLS CUI [1])
Cisplatin
Item
Total amount of cisplatin administered this reporting period
float
C0008838 (UMLS CUI [1])
Carboplatin
Item
Total amount of Carboplatin administerd
float
C0079083 (UMLS CUI [1])
Etoposide
Item
Total amount of Etoposide administered
float
C0015133 (UMLS CUI [1])
Mesna-Bolus
Item
Total amount of Mesna-Bolus administered
float
C0000294 (UMLS CUI [1])
Ifosfamide
Item
Total amount of Ifosfamide administered
float
C0020823 (UMLS CUI [1])
Cyclophosphamide
Item
Total amount of Cyclophosphamide administered
float
C0010583 (UMLS CUI [1])
Mesna
Item
Total amount of Mesna administered
float
C0000294 (UMLS CUI [1])
Sedation
Item
Total amount of medication given for sedation
float
C0344106 (UMLS CUI [1])
Other Medication
Item
Any other Medication administered
text
C0013227 (UMLS CUI [1])
Item Group
Correctness of information confirmed
Date
Item
Date
date
C0011008 (UMLS CUI [1])
Physician
Item
Treating Physician
text
C1710470 (UMLS CUI [1])
Responsible Person Signature
Item
Signature
text
C1550483 (UMLS CUI [1])
Item Group
Chemotherapy
Cycle
Item
Cycle number
integer
C2045829 (UMLS CUI [1])
Item
Day of Treatment
text
C3468389 (UMLS CUI [1])
Day of Treatment
Code List
Day of Treatment
CL Item
Day 2 , 2=Day 3 (1)
Medication
Item
Total amount of medication administered
text
C3174092 (UMLS CUI [1])
Etoposide
Item
Total amount of Etoposide administered
float
C0015133 (UMLS CUI [1])
Ifosfamide
Item
Total amount of Ifosfamide administered
float
C0020823 (UMLS CUI [1])
Cyclophosphamide
Item
Total amount of Cyclophosphamide administered
float
C0010583 (UMLS CUI [1])
Mesna
Item
Total amount of Mesna administered
float
C0000294 (UMLS CUI [1])
Other Medication
Item
Any other medication administered
text
C0013227 (UMLS CUI [1])
Item Group
Correctness of information confirmed
Date
Item
Date
date
C0011008 (UMLS CUI [1])
Physician
Item
Treating Physician
text
C1710470 (UMLS CUI [1])
Responsible Person Signature
Item
Signature
text
C1550483 (UMLS CUI [1])
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