Description:

S1011 Surgeon's Post-Op Data Form Standard Versus Extended LND (#19886) Standard or Extended Pelvic Lymphadenectomy in Treating Patients Undergoing Surgery for Invasive Bladder Cancer Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=940453E3-437B-BBC7-E040-BB89AD431F9F

Link:

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=940453E3-437B-BBC7-E040-BB89AD431F9F

Keywords:
Versions (4) ▾
  1. 8/26/12
  2. 11/28/14
  3. 1/9/15
  4. 1/9/15
Uploaded on:

January 9, 2015

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License:
Creative Commons BY-NC 3.0 Legacy
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Bladder Cancer NCT01224665 Treatment - S1011 Surgeon's Post-Op Data Form Standard Versus Extended LND (#19886) - 3153895v1.0

Instructions: To be completed by attending surgeon. Please complete within 7 days of hospital discharge. Surgeons should be provided with this form prior to the surgical event. All dates are MONTH, DAY, YEAR. Explain any blank fields or blank dates in the Comments section. Place an X in appropriate boxes. Circle AMENDED items in red and write AMENDED across top of form

Header Module
Hospitalization
Did patient require an unplanned admission to ICU at any time
Was TPN used postoperatively (Central/Total Parenteral Nutrition)
Were enteral tube feedings used postoperatively
Disease Description
Pathologic T Stage
Pathologic N Stage
Histologic Type (select all that apply)
Type of Variant Histology (if selected please specify)
Complications
Was the assessment done
Surgical Complications
Surgical Complication Grade
Transfusions
Comments