ID

9244

Description

Missed Visit (MV) Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=B12440AB-9301-4E9E-E034-0003BA12F5E7

Link

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=B12440AB-9301-4E9E-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 Follow-Up - Missed Visit (MV) - 2074838v3.0

English

Instructions: Complete and submit this form for each permanently missed scheduled visit ONLY. Indicate the code of the missed scheduled visit in the Visit Code data field above. Do not complete this form for delayed scheduled visits.

1 forms  
Ccrr Module For Missed Visit (mv)
Description

Ccrr Module For Missed Visit (mv)

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

Pt.ID

Data type

text

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

Missed Visit Date: (originally scheduled date)
Description

PatientAbsentVisitDate

Data type

date

Alias
NCI Thesaurus ValueDomain
C25164
UMLS 2011AA ValueDomain
C0011008
NCI Thesaurus ObjectClass
C16960
UMLS 2011AA ObjectClass
C0030705
NCI Thesaurus Property
C48190
UMLS 2011AA Property
C0332197
NCI Thesaurus Property-2
C25716
UMLS 2011AA Property-2
C0545082
Reason patient missed visit: (Mark only one.)
Description

PatientAbsentVisitReason

Data type

text

Alias
NCI Thesaurus ValueDomain
C25638
UMLS 2011AA ValueDomain
C0392360
NCI Thesaurus ObjectClass
C16960
UMLS 2011AA ObjectClass
C0030705
NCI Thesaurus Property
C48190
UMLS 2011AA Property
C0332197
NCI Thesaurus Property-2
C25716
UMLS 2011AA Property-2
C0545082
Other, (specify:)
Description

Other,

Data type

text

Completed by:
Description

CompletedBy

Data type

text

Date:
Description

FormCompletionDate,Original

Data type

date

Year Month Day
Description

YearMonthDay

Data type

text

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Similar models

Instructions: Complete and submit this form for each permanently missed scheduled visit ONLY. Indicate the code of the missed scheduled visit in the Visit Code data field above. Do not complete this form for delayed scheduled visits.

1 forms
Name
Type
Description | Question | Decode (Coded Value)
Data type
Alias
Item Group
Ccrr Module For Missed Visit (mv)
Pt.ID
Item
Patient ID (Pt. ID issued during registration or previously issued patient ID)
text
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
PatientAbsentVisitDate
Item
Missed Visit Date: (originally scheduled date)
date
C25164 (NCI Thesaurus ValueDomain)
C0011008 (UMLS 2011AA ValueDomain)
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C48190 (NCI Thesaurus Property)
C0332197 (UMLS 2011AA Property)
C25716 (NCI Thesaurus Property-2)
C0545082 (UMLS 2011AA Property-2)
Item
Reason patient missed visit: (Mark only one.)
text
C25638 (NCI Thesaurus ValueDomain)
C0392360 (UMLS 2011AA ValueDomain)
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C48190 (NCI Thesaurus Property)
C0332197 (UMLS 2011AA Property)
C25716 (NCI Thesaurus Property-2)
C0545082 (UMLS 2011AA Property-2)
CL.1
Code List
Reason patient missed visit: (Mark only one.)
CL Item
Health Reasons (Health reasons)
CL Item
Distance From Home To Clinical Site (Distance from home to clinical site)
CL Item
Scheduling Difficulties (Scheduling difficulties)
CL Item
Other (Other, specify:)
C17649 (NCI Thesaurus)
C0205394 (UMLS 2011AA)
Other,
Item
Other, (specify:)
text
CompletedBy
Item
Completed by:
text
FormCompletionDate,Original
Item
Date:
date
YearMonthDay
Item
Year Month Day
text
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