ID

18736

Beschreibung

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

Stichworte

Versionen (2)
  1. 23.07.16 23.07.16 -
  2. 18.11.16 18.11.16 -
Hochgeladen am

18. November 2016

DOI

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Lizenz

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

    Englisch

    Electrocardiogram Results: CRF Wisconsin Madison

    1 Formulare  
    Header
    Beschreibung

    Header

    PI Name
    Beschreibung

    PI Name

    Datentyp

    text

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

    Protocol or IRB Number

    Datentyp

    integer

    Alias
    UMLS CUI [1]
    C2348563
    Protocol Short Title
    Beschreibung

    Protocol Short Title

    Datentyp

    text

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

    Subject Initials

    Datentyp

    text

    Alias
    UMLS CUI [1]
    C2986440
    Subject ID
    Beschreibung

    Subject ID

    Datentyp

    integer

    Alias
    UMLS CUI [1]
    C2348585
    Electrocardiogram Results
    Beschreibung

    Electrocardiogram Results

    Date
    Beschreibung

    Date

    Datentyp

    date

    Alias
    UMLS CUI [1]
    C0011008
    Electrocardiogram not performed
    Beschreibung

    Electrocardiogram not performed

    Datentyp

    boolean

    Alias
    UMLS CUI [1]
    C0420795
    Time
    Beschreibung

    Time

    Datentyp

    time

    Alias
    UMLS CUI [1]
    C0040223
    Visit Number
    Beschreibung

    Visit Number

    Datentyp

    text

    Alias
    UMLS CUI [1]
    C1549755
    Position of Subject
    Beschreibung

    Position

    Datentyp

    text

    Alias
    UMLS CUI [1]
    C0733755
    ECG Measurement/ Result: Heart Rate
    Beschreibung

    ECG Measurement/ Result: Heart Rate

    Datentyp

    integer

    Maßeinheiten
    • bpm
    Alias
    UMLS CUI [1,1]
    C3642352
    UMLS CUI [1,2]
    C0018810
    bpm
    ECG Measurement/ Result: Heart Rate
    Beschreibung

    ECG Measurement/ Result: Heart Rate

    Datentyp

    text

    Alias
    UMLS CUI [1,1]
    C3642352
    UMLS CUI [1,2]
    C0018810
    ECG Measurement/ Result: Heart Rate Clinically significant
    Beschreibung

    ECG Measurement/ Result: Heart Rate

    Datentyp

    boolean

    Alias
    UMLS CUI [1,1]
    C3642352
    UMLS CUI [1,2]
    C0018810
    UMLS CUI [1,3]
    C2826293
    ECG Measurement/ Result: PR Interval
    Beschreibung

    ECG Measurement/ Result: PR Interval

    Datentyp

    integer

    Maßeinheiten
    • msec
    Alias
    UMLS CUI [1]
    C0429087
    msec
    ECG Measurement/ Result: PR Interval
    Beschreibung

    ECG Measurement/ Result: PR Interval

    Datentyp

    text

    Alias
    UMLS CUI [1]
    C0429087
    ECG Measurement/ Result: PR Interval Clinically significant
    Beschreibung

    ECG Measurement/ Result: PR Interval

    Datentyp

    boolean

    Alias
    UMLS CUI [1,1]
    C0429087
    UMLS CUI [1,2]
    C2826293
    ECG Measurement/ Result: QRS Duration
    Beschreibung

    ECG Measurement/ Result: QRS Duration

    Datentyp

    integer

    Maßeinheiten
    • msec
    Alias
    UMLS CUI [1,1]
    C3642352
    UMLS CUI [1,2]
    C0429025
    msec
    ECG Measurement/ Result: QRS Duration
    Beschreibung

    ECG Measurement/ Result: QRS Duration

    Datentyp

    text

    Alias
    UMLS CUI [1,1]
    C3642352
    UMLS CUI [1,2]
    C0429025
    ECG Measurement/ Result: QRS Duration Clinically significant
    Beschreibung

    ECG Measurement/ Result: QRS Duration

    Datentyp

    boolean

    Alias
    UMLS CUI [1,1]
    C3642352
    UMLS CUI [1,2]
    C0429025
    UMLS CUI [1,3]
    C2826293
    ECG Measurement/ Result: QTc Interval
    Beschreibung

    ECG Measurement/ Result: QTc Interval

    Datentyp

    integer

    Maßeinheiten
    • msec
    Alias
    UMLS CUI [1,1]
    C3642352
    UMLS CUI [1,2]
    C0489625
    msec
    ECG Measurement/ Result: QTc Interval
    Beschreibung

    ECG Measurement/ Result: QTc Interval

    Datentyp

    text

    Alias
    UMLS CUI [1,1]
    C3642352
    UMLS CUI [1,2]
    C0489625
    ECG Measurement/ Result: QTc Interval Clinically significant
    Beschreibung

    ECG Measurement/ Result: QTc Interval

    Datentyp

    boolean

    Alias
    UMLS CUI [1,1]
    C3642352
    UMLS CUI [1,2]
    C0489625
    UMLS CUI [1,3]
    C2826293
    Cardiac Rhythm
    Beschreibung

    Cardiac Rhythm

    Datentyp

    text

    Alias
    UMLS CUI [1]
    C0232187
    Cardiac Rhythm: If Other, please specify
    Beschreibung

    Cardiac Rhythm

    Datentyp

    text

    Alias
    UMLS CUI [1,1]
    C0232187
    UMLS CUI [1,2]
    C0205394
    Overall assessment
    Beschreibung

    Overall assessment

    Datentyp

    text

    Alias
    UMLS CUI [1]
    C0220825
    Overall assessment: Clinically significant
    Beschreibung

    Overall assessment

    Datentyp

    boolean

    Alias
    UMLS CUI [1,1]
    C0220825
    UMLS CUI [1,2]
    C2826293
    ECG done by
    Beschreibung

    ECG done by

    Datentyp

    text

    Alias
    UMLS CUI [1,1]
    C0013798
    UMLS CUI [1,2]
    C1550369
    ECG read by
    Beschreibung

    ECG read by

    Datentyp

    text

    Alias
    UMLS CUI [1,1]
    C0013798
    UMLS CUI [1,2]
    C0034754
    Comments
    Beschreibung

    Comments

    Datentyp

    text

    Alias
    UMLS CUI [1]
    C0947611
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    Ähnliche Modelle

    Electrocardiogram Results: CRF Wisconsin Madison

    1 Formulare
    Name
    Typ
    Description | Question | Decode (Coded Value)
    Datentyp
    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])
    Item Group
    Electrocardiogram Results
    Date
    Item
    Date
    date
    C0011008 (UMLS CUI [1])
    Electrocardiogram not performed
    Item
    Electrocardiogram not performed
    boolean
    C0420795 (UMLS CUI [1])
    Time
    Item
    Time
    time
    C0040223 (UMLS CUI [1])
    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)
    CL Item
    Visit # (7)
    CL Item
    Visit # (8)
    CL Item
    Visit # (9)
    Item
    Position of Subject
    text
    C0733755 (UMLS CUI [1])
    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
    C3642352 (UMLS CUI [1,1])
    C0018810 (UMLS CUI [1,2])
    Item
    ECG Measurement/ Result: Heart Rate
    text
    C3642352 (UMLS CUI [1,1])
    C0018810 (UMLS CUI [1,2])
    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
    C3642352 (UMLS CUI [1,1])
    C0018810 (UMLS CUI [1,2])
    C2826293 (UMLS CUI [1,3])
    ECG Measurement/ Result: PR Interval
    Item
    ECG Measurement/ Result: PR Interval
    integer
    C0429087 (UMLS CUI [1])
    Item
    ECG Measurement/ Result: PR Interval
    text
    C0429087 (UMLS CUI [1])
    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
    C0429087 (UMLS CUI [1,1])
    C2826293 (UMLS CUI [1,2])
    ECG Measurement/ Result: QRS Duration
    Item
    ECG Measurement/ Result: QRS Duration
    integer
    C3642352 (UMLS CUI [1,1])
    C0429025 (UMLS CUI [1,2])
    Item
    ECG Measurement/ Result: QRS Duration
    text
    C3642352 (UMLS CUI [1,1])
    C0429025 (UMLS CUI [1,2])
    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
    C3642352 (UMLS CUI [1,1])
    C0429025 (UMLS CUI [1,2])
    C2826293 (UMLS CUI [1,3])
    ECG Measurement/ Result: QTc Interval
    Item
    ECG Measurement/ Result: QTc Interval
    integer
    C3642352 (UMLS CUI [1,1])
    C0489625 (UMLS CUI [1,2])
    Item
    ECG Measurement/ Result: QTc Interval
    text
    C3642352 (UMLS CUI [1,1])
    C0489625 (UMLS CUI [1,2])
    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
    C3642352 (UMLS CUI [1,1])
    C0489625 (UMLS CUI [1,2])
    C2826293 (UMLS CUI [1,3])
    Item
    Cardiac Rhythm
    text
    C0232187 (UMLS CUI [1])
    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
    C0232187 (UMLS CUI [1,1])
    C0205394 (UMLS CUI [1,2])
    Item
    Overall assessment
    text
    C0220825 (UMLS CUI [1])
    Overall assessment
    Code List
    Overall assessment
    CL Item
    Normal (1)
    CL Item
    Abnormal (2)
    Overall assessment
    Item
    Overall assessment: Clinically significant
    boolean
    C0220825 (UMLS CUI [1,1])
    C2826293 (UMLS CUI [1,2])
    ECG done by
    Item
    ECG done by
    text
    C0013798 (UMLS CUI [1,1])
    C1550369 (UMLS CUI [1,2])
    ECG read by
    Item
    ECG read by
    text
    C0013798 (UMLS CUI [1,1])
    C0034754 (UMLS CUI [1,2])
    Comments
    Item
    Comments
    text
    C0947611 (UMLS CUI [1])
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