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ID

9244

Beskrivning

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

Länk

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=B12440AB-9301-4E9E-E034-0003BA12F5E7

Nyckelord

  1. 2012-09-19 2012-09-19 -
  2. 2015-01-09 2015-01-09 - Martin Dugas
Uppladdad den

9 januari 2015

DOI

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Licens

Creative Commons BY-NC 3.0 Legacy

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    Melanoma (Skin) null Follow-Up - Missed Visit (MV) - 2074838v3.0

    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.

    Ccrr Module For Missed Visit (mv)
    Beskrivning

    Ccrr Module For Missed Visit (mv)

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

    Pt.ID

    Datatyp

    text

    Institution ID:
    Beskrivning

    InstitutionNo.

    Datatyp

    text

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

    Patient Initials

    Datatyp

    text

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

    InstitutionName

    Datatyp

    text

    Missed Visit Date: (originally scheduled date)
    Beskrivning

    PatientAbsentVisitDate

    Datatyp

    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.)
    Beskrivning

    PatientAbsentVisitReason

    Datatyp

    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:)
    Beskrivning

    Other,

    Datatyp

    text

    Completed by:
    Beskrivning

    CompletedBy

    Datatyp

    text

    Date:
    Beskrivning

    FormCompletionDate,Original

    Datatyp

    date

    Year Month Day
    Beskrivning

    YearMonthDay

    Datatyp

    text

    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.

    Name
    Typ
    Description | Question | Decode (Coded Value)
    Datatyp
    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)
    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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