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Patient-reported Form (Baseline and Follow-up)

1 forms  
Administrative Data
Description

Administrative Data

Alias
UMLS CUI-1
C1320722
Indicate the patient's medical record number
Description

This number will not be shared with ICHOM. In the case patient-level data is submitted to ICHOM for benchmarking or research purposes, a separate ICHOM Patient Identifier will be created and cross-linking between the ICHOM Patient Identifier and the medical record number will only be known at the treating institution INCLUSION CRITERIA: All patients TIMING: On all forms REPORTING SOURCE: Administrative or clinical TYPE: Numerical RESPONSE OPTIONS: According to institution

Data type

integer

Alias
UMLS CUI [1]
C1269815
Time Relative to Baseline (e.g. Baseline, 6 months follow-up, 1 year follow-up, ...)
Description

This Item does not exist in the original standard set, instead it is asked to do the following: Please timestamp all variables. Some Standard Set variables are collected at multiple timepoints, and we will ask you to submit these variables in a concatenated VARIABLEID_TIMESTAMP form for future analyses. For example, VARIABLEID_BASE (baseline); VARIABLEID_6MO (6 month follow-up); VARIABLEID_1YR (1 year follow-up), etc.

Data type

text

Alias
UMLS CUI [1,1]
C0439564
UMLS CUI [1,2]
C1442488
Demographic factors
Description

Demographic factors

Alias
UMLS CUI-1
C1704791
What is your date of birth?
Description

INCLUSION CRITERIA: All patients TIMING: At time of diagnosis REPORTING SOURCE: Patient-reported, clinical, or administrative data TYPE: Date by DD/MM/YYYY

Data type

date

Measurement units
  • DD/MM/YYYY
Alias
UMLS CUI [1]
C0001779
UMLS CUI [2]
C0421451
DD/MM/YYYY
Please indicate your sex at birth
Description

INCLUSION CRITERIA: All patients TIMING: At time of diagnosis REPORTING SOURCE: Patient-reported, clinical, or administrative data TYPE: Single answer

Data type

integer

Alias
UMLS CUI [1]
C0079399
Patient-Reported Health Status
Description

Patient-Reported Health Status

Alias
UMLS CUI-1
C0018759
UMLS CUI-2
C2987124
Do you get out of breath in the following situations? When hurrying on ground level or walking up a slight hill
Description

INCLUSION CRITERIA: All patients TIMING: Baseline 30 days + annually up to 5 years after index event REPORTING SOURCE: Patient-reported TYPE: Single answer

Data type

integer

Alias
UMLS CUI [1]
C4288225
When walking with other people your age on level ground
Description

INCLUSION CRITERIA: All patients TIMING: Baseline 30 days + annually up to 5 years after index event REPORTING SOURCE: Patient-reported TYPE: Single answer

Data type

integer

Alias
UMLS CUI [1]
C2183407
When walking your own pace on level ground
Description

INCLUSION CRITERIA: All patients TIMING: Baseline 30 days + annually up to 5 years after index event REPORTING SOURCE: Patient-reported TYPE: Single answer

Data type

integer

Alias
UMLS CUI [1,1]
C2183407
UMLS CUI [1,2]
C3173662
When washing or dressing
Description

INCLUSION CRITERIA: All patients TIMING: Baseline 30 days + annually up to 5 years after index event REPORTING SOURCE: Patient-reported TYPE: Single answer

Data type

integer

Alias
UMLS CUI [1,1]
C0013404
UMLS CUI [1,2]
C3827978
Over the past 2 weeks, how often have you been bothered by any of the following problems? Little interest or pleasure in doing things
Description

INCLUSION CRITERIA: All patients TIMING: Baseline 30 days + annually up to 5 years after index event REPORTING SOURCE: Patient-reported TYPE: Single answer

Data type

integer

Alias
UMLS CUI [1]
C2707451
Feeling down, depressed or hopeless
Description

INCLUSION CRITERIA: All patients TIMING: Baseline 30 days + annually up to 5 years after index event REPORTING SOURCE: Patient-reported TYPE: Single answer

Data type

integer

Alias
UMLS CUI [1]
C2707455
SAQ-7 Total Score
Description

As a license is needed for use of this questionnaire, the 7 actual questions are not included in this version of the standard set. ICHOM IDs are SAQ7_Q01a up to SAQ7_Q05 INCLUSION CRITERIA: All patients TIMING: Baseline, 30 days + annually up to 5 years after index event REPORTING SOURCE: Patient-reported TYPE: Numerical (each question is single answer in original set)

Data type

integer

Alias
UMLS CUI [1,1]
C4695252
UMLS CUI [1,2]
C2964552
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Similar models

Patient-reported Form (Baseline and Follow-up)

1 forms
Name
Type
Description | Question | Decode (Coded Value)
Data type
Alias
Item Group
Administrative Data
C1320722 (UMLS CUI-1)
Patient ID
Item
Indicate the patient's medical record number
integer
C1269815 (UMLS CUI [1])
Time Relative to Baseline
Item
Time Relative to Baseline (e.g. Baseline, 6 months follow-up, 1 year follow-up, ...)
text
C0439564 (UMLS CUI [1,1])
C1442488 (UMLS CUI [1,2])
Item Group
Demographic factors
C1704791 (UMLS CUI-1)
Age
Item
What is your date of birth?
date
C0001779 (UMLS CUI [1])
C0421451 (UMLS CUI [2])
Item
Please indicate your sex at birth
integer
C0079399 (UMLS CUI [1])
Sex
Code List
Please indicate your sex at birth
CL Item
Male (1)
C0086582 (UMLS CUI-1)
(Comment:en)
CL Item
Female (2)
C0086287 (UMLS CUI-1)
(Comment:en)
Item Group
Patient-Reported Health Status
C0018759 (UMLS CUI-1)
C2987124 (UMLS CUI-2)
Item
Do you get out of breath in the following situations? When hurrying on ground level or walking up a slight hill
integer
C4288225 (UMLS CUI [1])
Past medical history: Previous AMI
Code List
Do you get out of breath in the following situations? When hurrying on ground level or walking up a slight hill
CL Item
No (0)
C1298908 (UMLS CUI-1)
(Comment:en)
CL Item
Yes (1)
C1705108 (UMLS CUI-1)
(Comment:en)
Item
When walking with other people your age on level ground
integer
C2183407 (UMLS CUI [1])
Past medical history: Previous AMI
Code List
When walking with other people your age on level ground
CL Item
No (0)
C1298908 (UMLS CUI-1)
(Comment:en)
CL Item
Yes (1)
C1705108 (UMLS CUI-1)
(Comment:en)
Item
When walking your own pace on level ground
integer
C2183407 (UMLS CUI [1,1])
C3173662 (UMLS CUI [1,2])
Past medical history: Previous AMI
Code List
When walking your own pace on level ground
CL Item
No (0)
C1298908 (UMLS CUI-1)
(Comment:en)
CL Item
Yes (1)
C1705108 (UMLS CUI-1)
(Comment:en)
Item
When washing or dressing
integer
C0013404 (UMLS CUI [1,1])
C3827978 (UMLS CUI [1,2])
Past medical history: Previous AMI
Code List
When washing or dressing
CL Item
No (0)
C1298908 (UMLS CUI-1)
(Comment:en)
CL Item
Yes (1)
C1705108 (UMLS CUI-1)
(Comment:en)
Item
Over the past 2 weeks, how often have you been bothered by any of the following problems? Little interest or pleasure in doing things
integer
C2707451 (UMLS CUI [1])
Past medical history: Previous AMI
Code List
Over the past 2 weeks, how often have you been bothered by any of the following problems? Little interest or pleasure in doing things
CL Item
Not at all (1)
C2984077 (UMLS CUI-1)
(Comment:en)
CL Item
Several days (2)
C3844034 (UMLS CUI-1)
(Comment:en)
CL Item
More than half the days (3)
C3828960 (UMLS CUI-1)
(Comment:en)
CL Item
Nearly every day (4)
C3845713 (UMLS CUI-1)
(Comment:en)
Item
Feeling down, depressed or hopeless
integer
C2707455 (UMLS CUI [1])
Past medical history: Previous AMI
Code List
Feeling down, depressed or hopeless
CL Item
Not at all (1)
C2984077 (UMLS CUI-1)
(Comment:en)
CL Item
Several days (2)
C3844034 (UMLS CUI-1)
(Comment:en)
CL Item
More than half the days (3)
C3828960 (UMLS CUI-1)
(Comment:en)
CL Item
Nearly every day (4)
C3845713 (UMLS CUI-1)
(Comment:en)
SAQ-7
Item
SAQ-7 Total Score
integer
C4695252 (UMLS CUI [1,1])
C2964552 (UMLS CUI [1,2])
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