Description:

Doods J, Botteri F, Dugas M, Fritz F; EHR4CR WP7. A European inventory of common electronic health record data elements for clinical trial feasibility. Trials. 2014 Jan 10;15:18 http://www.ncbi.nlm.nih.gov/pubmed/24410735

Link:

http://www.ncbi.nlm.nih.gov/pubmed/24410735

Keywords:

Reference Standards

Routine documentation

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Uploaded on:

September 20, 2021

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Creative Commons BY-NC 3.0

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EHR4CR data inventory

Details

EHR4CR data inventory

StudyEvent: Disease
1. EHR4CR data inventory

Demographics

Date of Birth

Admission Date

Discharge Date

Case Status

Medical History

Currently pregnant

Yes

No

Gravidity (no pregnancies)

Menauposal Status

Allergies oder Hypersensitivity reactions

Smoking Status

Alcohol Abuse

Substance Abuse

Diagnosis

Diagnosis Text

Diagnosis Date

Diagnosis Code

Histologically confirmed diagnosis

Procedure

Procedure Text

Procedure Code

Procedure Date

Findings

Date / Time of Finding

Body Weight

Body Height

Temperature

Blood pressure systolic

Blood pressure diastolic

Laboratory Findings

HER2 status

Yes

No

sampling Date / Time of Laboratory Finding

Total Cholesterol in serum

HDL in serum

LDL in serum

Triglycerides

Blood Urea Nitrogen [BUN] in serum

Calcium in serum

Creatinine in serum

Glucose in serum

Potassium in serum

Sodium in Serum

Alkaline Phosphatase

SGOT (AST)

SGPT (ALT)

Total Bilirubin in serum

Direct Bilirubin in serum

Total Protein in serum

Haemoglobin

Haematocrit

Platelets

Erythrocytes

Leukocytes

Neutrophils

Lymphocytes

Eosinophils

Beta HCG in serum

Cardiac troponin T

Medication

Verbatim Drug name

Medication Code

Medication start date

Medication end date

Drug class

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