ID

16548

Descrizione

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.

collegamento

https://ictr.wisc.edu/CaseReptTempt

Keywords

  1. 23/07/16 23/07/16 -
  2. 18/11/16 18/11/16 -
Caricato su

23 luglio 2016

DOI

Per favore, per richiedere un accesso.

Licenza

Creative Commons BY-NC 3.0

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Electrocardiogram Results: CRF Wisconsin Madison

Electrocardiogram Results: CRF Wisconsin Madison

Header
Descrizione

Header

PI Name
Descrizione

PI Name

Tipo di dati

text

Protocol or IRB Number
Descrizione

Protocol or IRB Number

Tipo di dati

integer

Protocol Short Title
Descrizione

Protocol Short Title

Tipo di dati

text

Subject Initials
Descrizione

Subject Initials

Tipo di dati

text

Subject ID
Descrizione

Subject ID

Tipo di dati

integer

Electrocardiogram Results
Descrizione

Electrocardiogram Results

Date
Descrizione

Date

Tipo di dati

date

Electrocardiogram not performed
Descrizione

Electrocardiogram not performed

Tipo di dati

boolean

Time
Descrizione

Time

Tipo di dati

time

Visit Number
Descrizione

Visit Number

Tipo di dati

text

Position of Subject
Descrizione

Position of Subject

Tipo di dati

text

ECG Measurement/ Result: Heart Rate
Descrizione

ECG Measurement/ Result: Heart Rate

Tipo di dati

integer

Unità di misura
  • bpm
bpm
ECG Measurement/ Result: Heart Rate
Descrizione

ECG Measurement/ Result: Heart Rate

Tipo di dati

text

ECG Measurement/ Result: Heart Rate Clinically significant
Descrizione

ECG Measurement/ Result: Heart Rate

Tipo di dati

boolean

ECG Measurement/ Result: PR Interval
Descrizione

ECG Measurement/ Result: PR Interval

Tipo di dati

integer

Unità di misura
  • msec
msec
ECG Measurement/ Result: PR Interval
Descrizione

ECG Measurement/ Result: PR Interval

Tipo di dati

text

ECG Measurement/ Result: PR Interval Clinically significant
Descrizione

ECG Measurement/ Result: PR Interval

Tipo di dati

boolean

ECG Measurement/ Result: QRS Duration
Descrizione

ECG Measurement/ Result: QRS Duration

Tipo di dati

integer

Unità di misura
  • msec
msec
ECG Measurement/ Result: QRS Duration
Descrizione

ECG Measurement/ Result: QRS Duration

Tipo di dati

text

ECG Measurement/ Result: QRS Duration Clinically significant
Descrizione

ECG Measurement/ Result: QRS Duration

Tipo di dati

boolean

ECG Measurement/ Result: QTc Interval
Descrizione

ECG Measurement/ Result: QTc Interval

Tipo di dati

integer

Unità di misura
  • msec
msec
ECG Measurement/ Result: QTc Interval
Descrizione

ECG Measurement/ Result: QTc Interval

Tipo di dati

text

ECG Measurement/ Result: QTc Interval Clinically significant
Descrizione

ECG Measurement/ Result: QTc Interval

Tipo di dati

boolean

Cardiac Rhythm
Descrizione

Cardiac Rhythm

Tipo di dati

text

Cardiac Rhythm: If Other, please specify
Descrizione

Cardiac Rhythm

Tipo di dati

text

Overall assessment
Descrizione

Overall assessment

Tipo di dati

text

Overall assessment: Clinically significant
Descrizione

Overall assessment

Tipo di dati

boolean

ECG done by
Descrizione

ECG done by

Tipo di dati

text

ECG read by
Descrizione

ECG read by

Tipo di dati

text

Comments
Descrizione

Comments

Tipo di dati

text

Similar models

Electrocardiogram Results: CRF Wisconsin Madison

Name
genere
Description | Question | Decode (Coded Value)
Tipo di dati
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
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
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
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
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
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
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
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
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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