0 Évaluations

ID

18733

Description

ODM Form derived from: https://ictr.wisc.edu/CaseReptTempt. Template Name: Concomitant Medication Log. 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.

Lien

https://ictr.wisc.edu/CaseReptTempt

Mots-clés

  1. 23/07/2016 23/07/2016 -
  2. 17/11/2016 17/11/2016 -
Téléchargé le

17 novembre 2016

DOI

Pour une demande vous connecter.

Licence

Creative Commons BY-NC 3.0

Modèle Commentaires :

Ici, vous pouvez faire des commentaires sur le modèle. À partir des bulles de texte, vous pouvez laisser des commentaires spécifiques sur les groupes Item et les Item.

Groupe Item commentaires pour :

Item commentaires pour :


    Aucun commentaire

    Vous devez être connecté pour pouvoir télécharger des formulaires. Veuillez vous connecter ou s’inscrire gratuitement.

    Concomitant Medication Log: CRF Wisconsin Madison

    Concomitant Medication Log: CRF Wisconsin Madison

    Header
    Description

    Header

    PI Name
    Description

    PI Name

    Type de données

    text

    Alias
    UMLS CUI [1,1]
    C0027365 (Name)
    SNOMED
    703503000
    LOINC
    LP72974-6
    UMLS CUI [1,2]
    C1521895 (Principal Investigator)
    SNOMED
    768818001
    Protocol or IRB Number
    Description

    Protocol or IRB Number

    Type de données

    integer

    Alias
    UMLS CUI [1]
    C2348563 (Study Protocol)
    Protocol Short Title
    Description

    Protocol Short Title

    Type de données

    text

    Alias
    UMLS CUI [1,1]
    C2348563 (Study Protocol)
    UMLS CUI [1,2]
    C1705824 (Trial Title)
    Subject Initials
    Description

    Subject Initials

    Type de données

    text

    Alias
    UMLS CUI [1]
    C2986440 (Person Initials)
    Subject ID
    Description

    Subject ID

    Type de données

    integer

    Alias
    UMLS CUI [1]
    C2348585 (Clinical Trial Subject Unique Identifier)
    Number of Page
    Description

    Number of Page

    Type de données

    integer

    Alias
    UMLS CUI [1,1]
    C1704732 (Page (document))
    UMLS CUI [1,2]
    C0449788 (Count of entities)
    SNOMED
    410681005
    Total amount of pages
    Description

    Total amount of pages

    Type de données

    integer

    Alias
    UMLS CUI [1,1]
    C1704732 (Page (document))
    UMLS CUI [1,2]
    C0449788 (Count of entities)
    SNOMED
    410681005
    Concomitant Medication Log
    Description

    Concomitant Medication Log

    Description

    #

    Type de données

    integer

    Medication/ Non-drug Therapy
    Description

    Medication/ Non-drug Therapy

    Type de données

    text

    Alias
    UMLS CUI [1]
    C0013227 (Pharmaceutical Preparations)
    SNOMED
    763158003
    LOINC
    LP100609-9
    UMLS CUI [2]
    C0087111 (Therapeutic procedure)
    SNOMED
    277132007
    LOINC
    LP21090-3
    Indication
    Description

    Indication

    Type de données

    text

    Alias
    UMLS CUI [1]
    C3146298 (Indication)
    Dose (per admin)
    Description

    Medication Dose

    Type de données

    float

    Alias
    UMLS CUI [1]
    C3174092 (Medication dose)
    LOINC
    LP116765-1
    Dose Units
    Description

    1= g 2= mg 3= ug 4= L 5= mL 6= IU 7= Other

    Type de données

    text

    Alias
    UMLS CUI [1,1]
    C0178602 (Dosage)
    SNOMED
    260911001
    LOINC
    LP7180-5
    UMLS CUI [1,2]
    C1519795 (Unit of Measure)
    SNOMED
    767524001
    Schedule/Frequency
    Description

    1= QD (once a day) 2= BID (twice a day) 3= TID (three times a day) 4= QID (four times a day) 5= QOD (every other day) 6= QM (every month) 7= QOM (every other month) 8= QH (every hour) 9= AC (before meals) 10= PC (after meals) 11= PRN (as needed) 12= Other

    Type de données

    text

    Alias
    UMLS CUI [1]
    C0013154 (Drug Administration Schedule)
    UMLS CUI [2]
    C0439603 (Frequencies (time pattern))
    SNOMED
    272123002
    LOINC
    LP130485-8
    Dose Form
    Description

    1= Tablet 2= Capsule 3= Ointment 4=Suppository 5=Aerosol 6=Spray 7=Suspension 8= Patch 9=Gas 10=Gel 11=Cream 12=Powder

    Type de données

    text

    Alias
    UMLS CUI [1]
    C0013058 (Dosage Forms)
    SNOMED
    736542009
    Route of Administration
    Description

    1= Oral 2= Topical 3= Subcutaneous 4= Intradermal 5= Transdermal 6= Intraocular 7= Intramuscular 8= Inhalation 9= Intravenous 10= Intraperitoneal 11= Nasal 12= Vaginal 13= Rectal 14= Other

    Type de données

    text

    Alias
    UMLS CUI [1]
    C3469597 (Administration of medication)
    SNOMED
    18629005
    Start Date
    Description

    Start Date

    Type de données

    date

    Alias
    UMLS CUI [1]
    C0808070 (Start Date)
    End Date
    Description

    End Date

    Type de données

    date

    Alias
    UMLS CUI [1]
    C0806020 (End date)
    SNOMED
    454551000124105
    LOINC
    MTHU008302
    Baseline Med
    Description

    Baseline Med

    Type de données

    boolean

    Alias
    UMLS CUI [1,1]
    C0013227 (Pharmaceutical Preparations)
    SNOMED
    763158003
    LOINC
    LP100609-9
    UMLS CUI [1,2]
    C1442488 (Baseline)
    LOINC
    LA16758-7
    Continuing at end of study
    Description

    Continuing at end of study

    Type de données

    boolean

    Alias
    UMLS CUI [1]
    C1553904 (continuing therapy)

    Similar models

    Concomitant Medication Log: CRF Wisconsin Madison

    Name
    Type
    Description | Question | Decode (Coded Value)
    Type de données
    Alias
    Item Group
    Header
    PI Name
    Item
    PI Name
    text
    C0027365 (UMLS CUI [1,1])
    C1521895 (UMLS CUI [1,2])
    Protocol or IRB Number
    Item
    Protocol or IRB Number
    integer
    C2348563 (UMLS CUI [1])
    Protocol Short Title
    Item
    Protocol Short Title
    text
    C2348563 (UMLS CUI [1,1])
    C1705824 (UMLS CUI [1,2])
    Subject Initials
    Item
    Subject Initials
    text
    C2986440 (UMLS CUI [1])
    Subject ID
    Item
    Subject ID
    integer
    C2348585 (UMLS CUI [1])
    Number of Page
    Item
    Number of Page
    integer
    C1704732 (UMLS CUI [1,1])
    C0449788 (UMLS CUI [1,2])
    Total amount of pages
    Item
    Total amount of pages
    integer
    C1704732 (UMLS CUI [1,1])
    C0449788 (UMLS CUI [1,2])
    Item Group
    Concomitant Medication Log
    #
    Item
    #
    integer
    Medication/ Non-drug Therapy
    Item
    Medication/ Non-drug Therapy
    text
    C0013227 (UMLS CUI [1])
    C0087111 (UMLS CUI [2])
    Indication
    Item
    Indication
    text
    C3146298 (UMLS CUI [1])
    Medication Dose
    Item
    Dose (per admin)
    float
    C3174092 (UMLS CUI [1])
    Dose Units
    Item
    Dose Units
    text
    C0178602 (UMLS CUI [1,1])
    C1519795 (UMLS CUI [1,2])
    Schedule/Frequency
    Item
    Schedule/Frequency
    text
    C0013154 (UMLS CUI [1])
    C0439603 (UMLS CUI [2])
    Dose Form
    Item
    Dose Form
    text
    C0013058 (UMLS CUI [1])
    Route of Administration
    Item
    Route of Administration
    text
    C3469597 (UMLS CUI [1])
    Start Date
    Item
    Start Date
    date
    C0808070 (UMLS CUI [1])
    End Date
    Item
    End Date
    date
    C0806020 (UMLS CUI [1])
    Baseline Med
    Item
    Baseline Med
    boolean
    C0013227 (UMLS CUI [1,1])
    C1442488 (UMLS CUI [1,2])
    Continuing at end of study
    Item
    Continuing at end of study
    boolean
    C1553904 (UMLS CUI [1])

    Do you need help on how to use the search function? Please watch the corresponding tutorial video for more details and learn how to use the search function most efficiently.

    Watch Tutorial