ID

18736

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

November 18, 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

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

integer

Alias
UMLS CUI [1]
C2348585
Electrocardiogram Results
Description

Electrocardiogram Results

Date
Description

Date

Data type

date

Alias
UMLS CUI [1]
C0011008
Electrocardiogram not performed
Description

Electrocardiogram not performed

Data type

boolean

Alias
UMLS CUI [1]
C0420795
Time
Description

Time

Data type

time

Alias
UMLS CUI [1]
C0040223
Visit Number
Description

Visit Number

Data type

text

Alias
UMLS CUI [1]
C1549755
Position of Subject
Description

Position

Data type

text

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

ECG Measurement/ Result: Heart Rate

Data type

integer

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

ECG Measurement/ Result: Heart Rate

Data type

text

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

ECG Measurement/ Result: Heart Rate

Data type

boolean

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

ECG Measurement/ Result: PR Interval

Data type

integer

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

ECG Measurement/ Result: PR Interval

Data type

text

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

ECG Measurement/ Result: PR Interval

Data type

boolean

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

ECG Measurement/ Result: QRS Duration

Data type

integer

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

ECG Measurement/ Result: QRS Duration

Data type

text

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

ECG Measurement/ Result: QRS Duration

Data type

boolean

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

ECG Measurement/ Result: QTc Interval

Data type

integer

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

ECG Measurement/ Result: QTc Interval

Data type

text

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

ECG Measurement/ Result: QTc Interval

Data type

boolean

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

Cardiac Rhythm

Data type

text

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

Cardiac Rhythm

Data type

text

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

Overall assessment

Data type

text

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

Overall assessment

Data type

boolean

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

ECG done by

Data type

text

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

ECG read by

Data type

text

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

Comments

Data type

text

Alias
UMLS CUI [1]
C0947611
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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
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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