Englisch

Concomitant Medications (Non-Continuous Infusion)

1 Formulare  
Administrative Data
Beschreibung

Administrative Data

Alias
UMLS CUI-1
C1320722
Site #
Beschreibung

Study centre number

Datentyp

integer

Alias
UMLS CUI [1,1]
C0600091
UMLS CUI [1,2]
C0019994
Patient #
Beschreibung

patient ID

Datentyp

integer

Alias
UMLS CUI [1]
C2348585
Visit Date
Beschreibung

visit date

Datentyp

date

Alias
UMLS CUI [1]
C1320303
Investigator Name
Beschreibung

Investigator Name

Datentyp

text

Alias
UMLS CUI [1]
C2826892
Check if (additional) supplemental instance of this form was used.
Beschreibung

Check this box on all instances except for the last one.

Datentyp

boolean

Alias
UMLS CUI [1]
C1706499
Instance Number
Beschreibung

Fill in the instance number, starting from 1. On all instances except for the last one, the preceding box has to be checked.

Datentyp

integer

Alias
UMLS CUI [1,1]
C1516308
UMLS CUI [1,2]
C2348184
Check if No Concomitant Medications were given:
Beschreibung

Check if No Concomitant Medications were given:

Alias
UMLS CUI-1
C2347852
UMLS CUI-2
C1705847
UMLS CUI-3
C1511497
UMLS CUI-4
C0549184
Check if No Concomitant Medications were given:
Beschreibung

(except for continuous IV infusions) Otherwise, please complete below and do not record more than ONE medication on same instance. Include all medications taken within 14 days, and all investigational drugs taken within 30 days (if investigational drug is administered within 30 days, please contact Medical Monitor [protocol violation]), prior to initiation of Argatroban infusion, and throughout study and 30-day follow-up period.

Datentyp

boolean

Alias
UMLS CUI [1,1]
C2347852
UMLS CUI [1,2]
C1705847
UMLS CUI [1,3]
C1511497
UMLS CUI [1,4]
C0549184
Concomintant Medications (Non-Continuous Infusion)
Beschreibung

Concomintant Medications (Non-Continuous Infusion)

Alias
UMLS CUI-1
C2347852
UMLS CUI-2
C1705847
UMLS CUI-3
C1511497
Line #
Beschreibung

Use a new instance if more than 6 lines are required. Also do not record more than ONE medication on the same instance.

Datentyp

integer

Alias
UMLS CUI [1]
C2348184
Drug Name
Beschreibung

(Prefer Trade Name)

Datentyp

text

Alias
UMLS CUI [1,1]
C2360065
UMLS CUI [1,2]
C2347852
Dose (Include Units)
Beschreibung

Concomitant agent dose and dose unit

Datentyp

text

Alias
UMLS CUI [1,1]
C2347852
UMLS CUI [1,2]
C3174092
UMLS CUI [2]
C2826646
Route
Beschreibung

Concomitant agent route of admission

Datentyp

text

Alias
UMLS CUI [1,1]
C2347852
UMLS CUI [1,2]
C0013153
Route - specify:
Beschreibung

Concomitant agent route of admission - specify

Datentyp

text

Alias
UMLS CUI [1,1]
C2347852
UMLS CUI [1,2]
C0013153
UMLS CUI [1,3]
C1521902
Frequency
Beschreibung

Concomitant agent dosing frequency

Datentyp

text

Alias
UMLS CUI [1]
C2826654
Start Date
Beschreibung

(dd-mmm-yyyy)

Datentyp

date

Alias
UMLS CUI [1,1]
C2347852
UMLS CUI [1,2]
C0808070
Start Time
Beschreibung

(0000-2359)

Datentyp

time

Alias
UMLS CUI [1,1]
C2347852
UMLS CUI [1,2]
C1301880
Stop Date
Beschreibung

(dd-mmm-yyyy)

Datentyp

date

Alias
UMLS CUI [1,1]
C2347852
UMLS CUI [1,2]
C0806020
Stop Time
Beschreibung

(0000-2359)

Datentyp

time

Alias
UMLS CUI [1,1]
C2347852
UMLS CUI [1,2]
C1522314
Check if Ongoing
Beschreibung

Concomitant agent ongoing

Datentyp

boolean

Alias
UMLS CUI [1]
C2826666
Indication
Beschreibung

Concomitant agent indication

Datentyp

text

Alias
UMLS CUI [1,1]
C2347852
UMLS CUI [1,2]
C3146298
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Ähnliche Modelle

Concomitant Medications (Non-Continuous Infusion)

1 Formulare
Name
Typ
Description | Question | Decode (Coded Value)
Datentyp
Alias
Item Group
Administrative Data
C1320722 (UMLS CUI-1)
Study centre number
Item
Site #
integer
C0600091 (UMLS CUI [1,1])
C0019994 (UMLS CUI [1,2])
patient ID
Item
Patient #
integer
C2348585 (UMLS CUI [1])
visit date
Item
Visit Date
date
C1320303 (UMLS CUI [1])
Investigator Name
Item
Investigator Name
text
C2826892 (UMLS CUI [1])
Additional form
Item
Check if (additional) supplemental instance of this form was used.
boolean
C1706499 (UMLS CUI [1])
CRF Sequential Number
Item
Instance Number
integer
C1516308 (UMLS CUI [1,1])
C2348184 (UMLS CUI [1,2])
Item Group
Check if No Concomitant Medications were given:
C2347852 (UMLS CUI-1)
C1705847 (UMLS CUI-2)
C1511497 (UMLS CUI-3)
C0549184 (UMLS CUI-4)
No concomitant medications
Item
Check if No Concomitant Medications were given:
boolean
C2347852 (UMLS CUI [1,1])
C1705847 (UMLS CUI [1,2])
C1511497 (UMLS CUI [1,3])
C0549184 (UMLS CUI [1,4])
Item Group
Concomintant Medications (Non-Continuous Infusion)
C2347852 (UMLS CUI-1)
C1705847 (UMLS CUI-2)
C1511497 (UMLS CUI-3)
Sequence number
Item
Line #
integer
C2348184 (UMLS CUI [1])
Concomitant agent name
Item
Drug Name
text
C2360065 (UMLS CUI [1,1])
C2347852 (UMLS CUI [1,2])
Concomitant agent dose and dose unit
Item
Dose (Include Units)
text
C2347852 (UMLS CUI [1,1])
C3174092 (UMLS CUI [1,2])
C2826646 (UMLS CUI [2])
Item
Route
text
C2347852 (UMLS CUI [1,1])
C0013153 (UMLS CUI [1,2])
Concomitant agent route of admission
Code List
Route
CL Item
oral  (1)
CL Item
intravenous (2)
CL Item
subcutaneous (3)
CL Item
topical (4)
CL Item
inhalation (5)
CL Item
transdermal (6)
CL Item
rectal (7)
CL Item
Other, specify (8)
Concomitant agent route of admission - specify
Item
Route - specify:
text
C2347852 (UMLS CUI [1,1])
C0013153 (UMLS CUI [1,2])
C1521902 (UMLS CUI [1,3])
Concomitant agent dosing frequency
Item
Frequency
text
C2826654 (UMLS CUI [1])
Concomitant agent start date
Item
Start Date
date
C2347852 (UMLS CUI [1,1])
C0808070 (UMLS CUI [1,2])
Concomitant agent start time
Item
Start Time
time
C2347852 (UMLS CUI [1,1])
C1301880 (UMLS CUI [1,2])
Concomitant agent stop date
Item
Stop Date
date
C2347852 (UMLS CUI [1,1])
C0806020 (UMLS CUI [1,2])
Concomitant agent stop time
Item
Stop Time
time
C2347852 (UMLS CUI [1,1])
C1522314 (UMLS CUI [1,2])
Concomitant agent ongoing
Item
Check if Ongoing
boolean
C2826666 (UMLS CUI [1])
Concomitant agent indication
Item
Indication
text
C2347852 (UMLS CUI [1,1])
C3146298 (UMLS CUI [1,2])
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