ID

9225

Description

Surgical Report (SR) Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=B1229F05-2708-4D58-E034-0003BA12F5E7

Link

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=B1229F05-2708-4D58-E034-0003BA12F5E7

Keywords

Versions (2)
  1. 9/19/12 9/19/12 -
  2. 1/9/15 1/9/15 - Martin Dugas
Uploaded on

January 9, 2015

DOI

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License

Creative Commons BY-NC 3.0 Legacy
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Melanoma (Skin) null Treatment - Surgical Report (SR) - 2074581v3.0

English

No Instruction available.

1 forms  
  1. StudyEvent: Surgical Report (SR)
    1. No Instruction available.
Type Of Procedure
Description

Type Of Procedure

Excision/Sentinel Node Biopsy
Description

SentinelNodeBiopsyInd

Data type

boolean

Completion Lymphadenectomy
Description

LymphNodeSamplingInd

Data type

boolean

Location(s) of basin(s):
Description

DiseaseSite,LymphNodes

Data type

text

Re-excision
Description

Re-excision

Data type

boolean

Alias
NCI Thesaurus ValueDomain
C38148
UMLS 2011AA ValueDomain
C1512699
Indication:
Description

Indication:

Data type

text

Other, specify (Other, specify)
Description

Other,specify

Data type

text

Adjunctive Procedure: (Mark only one)
Description

AdjunctiveProcedure:

Data type

text

Name of surgeon responsible for case:
Description

SurgeonName

Data type

text

Signature of surgeon/PI:
Description

SurgeonSignature

Data type

text

Alias
NCI Thesaurus Property
C25678
UMLS 2011AA Property
C1519316
NCI Thesaurus ObjectClass
C18071
UMLS 2011AA ObjectClass
C0582175
Completed by:
Description

CompletedBy

Data type

text

Date: (Year Month Day)
Description

FormCompletionDate,Original

Data type

date

Date: (Year Month Day)
Description

FormCompletionDate,Original

Data type

date

Ccrr Module For Surgical Report (sr)
Description

Ccrr Module For Surgical Report (sr)

Patient ID (Pt. ID issued during registration or previously issued patient ID)
Description

PatientIdentifier

Data type

text

Alias
NCI Thesaurus ObjectClass
C16960
UMLS 2011AA ObjectClass
C0030705
NCI Thesaurus Property
C25364
UMLS 2011AA Property
C0600091
NCI Thesaurus ValueDomain
C25364
UMLS 2011AA ValueDomain
C0600091
Institution ID:
Description

InstitutionNo.

Data type

text

Alias
NCI Thesaurus ValueDomain
C25337
UMLS 2011AA ValueDomain
C0237753
Patient Initials: (F ML)
Description

Patient Initials

Data type

text

Alias
NCI Thesaurus ValueDomain
C25191
UMLS CUI-1
C2986440
NCI Thesaurus ObjectClass
C16960
NCI Thesaurus Property
C25536
Institution:
Description

InstitutionName

Data type

text

Date of Surgery: (within 30 days of randomization)
Description

SurgeryDate

Data type

date

Type of Surgery:
Description

TypeofSurgery:

Data type

text

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Similar models

No Instruction available.

1 forms
  1. StudyEvent: Surgical Report (SR)
    1. No Instruction available.
Name
Type
Description | Question | Decode (Coded Value)
Data type
Alias
Item Group
Type Of Procedure
SentinelNodeBiopsyInd
Item
Excision/Sentinel Node Biopsy
boolean
LymphNodeSamplingInd
Item
Completion Lymphadenectomy
boolean
DiseaseSite,LymphNodes
Item
Location(s) of basin(s):
text
Re-excision
Item
Re-excision
boolean
C38148 (NCI Thesaurus ValueDomain)
C1512699 (UMLS 2011AA ValueDomain)
Item
Indication:
text
CL.4
Code List
Indication:
CL Item
Invasive Primary Tumor Present Within 1 Mm Of Any Margin (Invasive primary tumor present within 1 mm of any margin)
CL Item
Microsatellite Tumor Present Within 1mm Of Any Margin (Microsatellite tumor present within 1mm of any margin)
CL Item
In Situ Tumor Present At Any Margin (In Situ tumor present at any margin)
CL Item
Other, Specify (Other, specify)
Other,specify
Item
Other, specify (Other, specify)
text
Item
Adjunctive Procedure: (Mark only one)
text
CL.5
Code List
Adjunctive Procedure: (Mark only one)
CL Item
Primary Closure With Or Without Undermining (Primary closure with or without undermining)
CL Item
Reconstructive Flap And/or Skin Graft (Reconstructive flap and/or skin graft)
SurgeonName
Item
Name of surgeon responsible for case:
text
SurgeonSignature
Item
Signature of surgeon/PI:
text
C25678 (NCI Thesaurus Property)
C1519316 (UMLS 2011AA Property)
C18071 (NCI Thesaurus ObjectClass)
C0582175 (UMLS 2011AA ObjectClass)
CompletedBy
Item
Completed by:
text
FormCompletionDate,Original
Item
Date: (Year Month Day)
date
FormCompletionDate,Original
Item
Date: (Year Month Day)
date
Item Group
Ccrr Module For Surgical Report (sr)
PatientIdentifier
Item
Patient ID (Pt. ID issued during registration or previously issued patient ID)
text
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C25364 (NCI Thesaurus Property)
C0600091 (UMLS 2011AA Property)
C25364 (NCI Thesaurus ValueDomain)
C0600091 (UMLS 2011AA ValueDomain)
InstitutionNo.
Item
Institution ID:
text
C25337 (NCI Thesaurus ValueDomain)
C0237753 (UMLS 2011AA ValueDomain)
Patient Initials
Item
Patient Initials: (F ML)
text
C25191 (NCI Thesaurus ValueDomain)
C2986440 (UMLS CUI-1)
C16960 (NCI Thesaurus ObjectClass)
C25536 (NCI Thesaurus Property)
InstitutionName
Item
Institution:
text
SurgeryDate
Item
Date of Surgery: (within 30 days of randomization)
date
TypeofSurgery:
Item
Type of Surgery:
text
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