ID

16548

Description

ODM Form derived from: https://ictr.wisc.edu/CaseReptTempt. Template Name: Electrocardiogram Results. 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

Keywords

Versions (2)
  1. 7/23/16 7/23/16 -
  2. 11/18/16 11/18/16 -
Uploaded on

July 23, 2016

DOI

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License

Creative Commons BY-NC 3.0
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Electrocardiogram Results: CRF Wisconsin Madison

English

Electrocardiogram Results: CRF Wisconsin Madison

1 forms  
Header
Description

Header

PI Name
Description

PI Name

Data type

text

Protocol or IRB Number
Description

Protocol or IRB Number

Data type

integer

Protocol Short Title
Description

Protocol Short Title

Data type

text

Subject Initials
Description

Subject Initials

Data type

text

Subject ID
Description

Subject ID

Data type

integer

Electrocardiogram Results
Description

Electrocardiogram Results

Date
Description

Date

Data type

date

Electrocardiogram not performed
Description

Electrocardiogram not performed

Data type

boolean

Time
Description

Time

Data type

time

Visit Number
Description

Visit Number

Data type

text

Position of Subject
Description

Position of Subject

Data type

text

ECG Measurement/ Result: Heart Rate
Description

ECG Measurement/ Result: Heart Rate

Data type

integer

Measurement units
  • bpm
bpm
ECG Measurement/ Result: Heart Rate
Description

ECG Measurement/ Result: Heart Rate

Data type

text

ECG Measurement/ Result: Heart Rate Clinically significant
Description

ECG Measurement/ Result: Heart Rate

Data type

boolean

ECG Measurement/ Result: PR Interval
Description

ECG Measurement/ Result: PR Interval

Data type

integer

Measurement units
  • msec
msec
ECG Measurement/ Result: PR Interval
Description

ECG Measurement/ Result: PR Interval

Data type

text

ECG Measurement/ Result: PR Interval Clinically significant
Description

ECG Measurement/ Result: PR Interval

Data type

boolean

ECG Measurement/ Result: QRS Duration
Description

ECG Measurement/ Result: QRS Duration

Data type

integer

Measurement units
  • msec
msec
ECG Measurement/ Result: QRS Duration
Description

ECG Measurement/ Result: QRS Duration

Data type

text

ECG Measurement/ Result: QRS Duration Clinically significant
Description

ECG Measurement/ Result: QRS Duration

Data type

boolean

ECG Measurement/ Result: QTc Interval
Description

ECG Measurement/ Result: QTc Interval

Data type

integer

Measurement units
  • msec
msec
ECG Measurement/ Result: QTc Interval
Description

ECG Measurement/ Result: QTc Interval

Data type

text

ECG Measurement/ Result: QTc Interval Clinically significant
Description

ECG Measurement/ Result: QTc Interval

Data type

boolean

Cardiac Rhythm
Description

Cardiac Rhythm

Data type

text

Cardiac Rhythm: If Other, please specify
Description

Cardiac Rhythm

Data type

text

Overall assessment
Description

Overall assessment

Data type

text

Overall assessment: Clinically significant
Description

Overall assessment

Data type

boolean

ECG done by
Description

ECG done by

Data type

text

ECG read by
Description

ECG read by

Data type

text

Comments
Description

Comments

Data type

text

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Similar models

Electrocardiogram Results: CRF Wisconsin Madison

1 forms
Name
Type
Description | Question | Decode (Coded Value)
Data type
Alias
Item Group
Header
PI Name
Item
PI Name
text
Protocol or IRB Number
Item
Protocol or IRB Number
integer
Protocol Short Title
Item
Protocol Short Title
text
Subject Initials
Item
Subject Initials
text
Subject ID
Item
Subject ID
integer
Item Group
Electrocardiogram Results
Date
Item
Date
date
Electrocardiogram not performed
Item
Electrocardiogram not performed
boolean
Time
Item
Time
time
Item
Visit Number
text
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)
CL Item
Visit # (7)
CL Item
Visit # (8)
CL Item
Visit # (9)
Item
Position of Subject
text
Position of Subject
Code List
Position of Subject
CL Item
Sitting (1)
CL Item
Supine (2)
ECG Measurement/ Result: Heart Rate
Item
ECG Measurement/ Result: Heart Rate
integer
Item
ECG Measurement/ Result: Heart Rate
text
ECG Measurement/ Result: Heart Rate
Code List
ECG Measurement/ Result: Heart Rate
CL Item
Normal (1)
CL Item
Abnormal (2)
ECG Measurement/ Result: Heart Rate
Item
ECG Measurement/ Result: Heart Rate Clinically significant
boolean
ECG Measurement/ Result: PR Interval
Item
ECG Measurement/ Result: PR Interval
integer
Item
ECG Measurement/ Result: PR Interval
text
ECG Measurement/ Result: PR Interval
Code List
ECG Measurement/ Result: PR Interval
CL Item
Normal (1)
CL Item
Abnormal (2)
ECG Measurement/ Result: PR Interval
Item
ECG Measurement/ Result: PR Interval Clinically significant
boolean
ECG Measurement/ Result: QRS Duration
Item
ECG Measurement/ Result: QRS Duration
integer
Item
ECG Measurement/ Result: QRS Duration
text
ECG Measurement/ Result: QRS Duration
Code List
ECG Measurement/ Result: QRS Duration
CL Item
Normal (1)
CL Item
Abnormal (2)
ECG Measurement/ Result: QRS Duration
Item
ECG Measurement/ Result: QRS Duration Clinically significant
boolean
ECG Measurement/ Result: QTc Interval
Item
ECG Measurement/ Result: QTc Interval
integer
Item
ECG Measurement/ Result: QTc Interval
text
ECG Measurement/ Result: QTc Interval
Code List
ECG Measurement/ Result: QTc Interval
CL Item
Normal (1)
CL Item
Abnormal (2)
ECG Measurement/ Result: QTc Interval
Item
ECG Measurement/ Result: QTc Interval Clinically significant
boolean
Item
Cardiac Rhythm
text
Cardiac Rhythm
Code List
Cardiac Rhythm
CL Item
Normal Sinus Rhythm (1)
CL Item
Atrial Fibrillation (2)
CL Item
First-degree Av Block (3)
CL Item
Ventricular Tachycardia  (4)
CL Item
Sinus Bradycardia (5)
CL Item
Atrial Flutter (6)
CL Item
Type I Second Degree Av Block (7)
CL Item
Type II Second Degree AV Block (8)
CL Item
Ventricular Fibrillation (9)
CL Item
Other: (specify) (10)
CL Item
Sinus Tachycardia (11)
CL Item
Supra Ventricular Tachycardia (12)
CL Item
Third Degree AV Block (13)
CL Item
Paced Rhythm  (14)
CL Item
Other: (specify) (15)
Cardiac Rhythm
Item
Cardiac Rhythm: If Other, please specify
text
Item
Overall assessment
text
Overall assessment
Code List
Overall assessment
CL Item
Normal (1)
CL Item
Abnormal (2)
Overall assessment
Item
Overall assessment: Clinically significant
boolean
ECG done by
Item
ECG done by
text
ECG read by
Item
ECG read by
text
Comments
Item
Comments
text
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