ID

18734

Description

ODM Form derived from: https://ictr.wisc.edu/CaseReptTempt. Template Name: Physical Examination. 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. 11/17/16 11/17/16 -
Uploaded on

November 17, 2016

DOI

To request one please log in.

License

Creative Commons BY-NC 3.0
Model comments :

You can comment on the data model here. Via the speech bubbles at the itemgroups and items you can add comments to those specificially.

Back to model comments
Itemgroup comments for :

Item comments for :

In order to download data models you must be logged in. Please log in or register for free.

Physical Examination: CRF Wisconsin Madison

English

Physical Examination: CRF Wisconsin Madison

1 forms  
Header
Description

Header

PI Name
Description

PI Name

Data type

text

Alias
UMLS CUI [1,1]
C0027365
UMLS CUI [1,2]
C1521895
Protocol or IRB Number
Description

Protocol or IRB Number

Data type

integer

Alias
UMLS CUI [1]
C2348563
Protocol Short Title
Description

Protocol Short Title

Data type

text

Alias
UMLS CUI [1,1]
C2348563
UMLS CUI [1,2]
C1705824
Subject Initials
Description

Subject Initials

Data type

text

Alias
UMLS CUI [1]
C2986440
Subject ID
Description

Subject ID

Data type

text

Alias
UMLS CUI [1]
C2348585
Exam Date
Description

Exam Date

Data type

date

Alias
UMLS CUI [1]
C2826643
Physical Examination
Description

Physical Examination

Time
Description

Time

Data type

time

Alias
UMLS CUI [1]
C0040223
Physical Examination not performed
Description

Physical Examination not performed

Data type

boolean

Alias
UMLS CUI [1,1]
C0031809
UMLS CUI [1,2]
C0445106
Visit Number
Description

Visit Number

Data type

text

Alias
UMLS CUI [1]
C1549755
Body System
Description

Body System

Body system to be examined
Description

Body System

Data type

text

Alias
UMLS CUI [1]
C0460002
Finding
Description

Finding

Data type

text

Alias
UMLS CUI [1]
C0243095
Comments (required if Abnormal)
Description

Comments

Data type

text

Alias
UMLS CUI [1]
C0947611
Clinically Significant
Description

Clinically Significant

Data type

boolean

Alias
UMLS CUI [1]
C2826293
Other
Description

Other

Other (specify in Comments)
Description

Other

Data type

text

Alias
UMLS CUI [1]
C0205394
Finding
Description

Finding

Data type

text

Alias
UMLS CUI [1]
C0243095
Comments (required if Abnormal)
Description

Comments

Data type

text

Alias
UMLS CUI [1]
C0947611
Clinically Significant
Description

Clinically Significant

Data type

boolean

Alias
UMLS CUI [1]
C2826293
Additional notes
Description

Additional notes

Data type

text

Alias
UMLS CUI [1]
C0947611
Physical Examination performed by
Description

Physical Examination performed by

Data type

text

Alias
UMLS CUI [1,1]
C0031809
UMLS CUI [1,2]
C1550369
Principal Investigator Signature
Description

Principal Investigator Signature

Data type

text

Alias
UMLS CUI [1,1]
C1519316
UMLS CUI [1,2]
C1521895
Date
Description

Date

Data type

date

Alias
UMLS CUI [1]
C0011008
Back to the top of the page

Similar models

Physical Examination: CRF Wisconsin Madison

1 forms
Name
Type
Description | Question | Decode (Coded Value)
Data type
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
text
C2348585 (UMLS CUI [1])
Exam Date
Item
Exam Date
date
C2826643 (UMLS CUI [1])
Item Group
Physical Examination
Time
Item
Time
time
C0040223 (UMLS CUI [1])
Physical Examination not performed
Item
Physical Examination not performed
boolean
C0031809 (UMLS CUI [1,1])
C0445106 (UMLS CUI [1,2])
Item
Visit Number
text
C1549755 (UMLS CUI [1])
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)
Item Group
Body System
Body System
Item
Body system to be examined
text
C0460002 (UMLS CUI [1])
Item
Finding
text
C0243095 (UMLS CUI [1])
Finding
Code List
Finding
CL Item
Normal (1)
CL Item
Abnormal (2)
CL Item
Not examined (3)
Comments
Item
Comments (required if Abnormal)
text
C0947611 (UMLS CUI [1])
Clinically Significant
Item
Clinically Significant
boolean
C2826293 (UMLS CUI [1])
Item Group
Other
Other
Item
Other (specify in Comments)
text
C0205394 (UMLS CUI [1])
Item
Finding
text
C0243095 (UMLS CUI [1])
Finding
Code List
Finding
CL Item
Normal (1)
CL Item
Abnormal (2)
CL Item
Not examined (3)
Comments
Item
Comments (required if Abnormal)
text
C0947611 (UMLS CUI [1])
Clinically Significant
Item
Clinically Significant
boolean
C2826293 (UMLS CUI [1])
Additional notes
Item
Additional notes
text
C0947611 (UMLS CUI [1])
Physical Examination performed by
Item
Physical Examination performed by
text
C0031809 (UMLS CUI [1,1])
C1550369 (UMLS CUI [1,2])
Principal Investigator Signature
Item
Principal Investigator Signature
text
C1519316 (UMLS CUI [1,1])
C1521895 (UMLS CUI [1,2])
Date
Item
Date
date
C0011008 (UMLS CUI [1])
Back to the top of the page 

Contact

Please use this form for feedback, questions and suggestions for improvements.

Fields marked with * are required.

Help

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