Group 2 Patients Only This form, together with the report of the arterial catheter flow, is required whenever a Group 2 patient has an MAA-HAI scan

Name
Type
Description | Question | Decode (Coded Value)
Data type
Alias
Item Group
Header
Patient Initials
Item
Patient Initials (Last First Middle)
text
C25191 (NCI Thesaurus ValueDomain)
C2986440 (UMLS CUI-1)
C16960 (NCI Thesaurus ObjectClass)
C25536 (NCI Thesaurus Property)
Patient ID NSABP
Item
NSABP Patient ID
text
C25337 (NCI Thesaurus ValueDomain)
C2348585 (UMLS CUI-1)
C16960 (NCI Thesaurus ObjectClass)
C1513905 (UMLS CUI-2)
C25364 (NCI Thesaurus Property)
C15818 (NCI Thesaurus Property-2)
Institution Name
Item
Institution Name
text
C25191 (NCI Thesaurus ValueDomain)
C1301943 (UMLS CUI-1)
C21541 (NCI Thesaurus ObjectClass)
C21541 (NCI Thesaurus ValueDomain-2)
C25364 (NCI Thesaurus Property)
Affiliate Name
Item
Affiliate Name
text
C21541 (NCI Thesaurus ObjectClass)
C1510825 (UMLS CUI-1)
C25413 (NCI Thesaurus ObjectClass-2)
C25364 (NCI Thesaurus Property)
C25191 (NCI Thesaurus ValueDomain)
C21541 (NCI Thesaurus ValueDomain-2)
Person Completing Form Last Name
Item
Person Completing Form Last Name
text
C25190 (NCI Thesaurus ObjectClass)
C1550483 (UMLS CUI-1)
C25657 (NCI Thesaurus ObjectClass-2)
C1301584 (UMLS CUI-2)
C25364 (NCI Thesaurus Property)
C25551 (NCI Thesaurus Property-2)
C25191 (NCI Thesaurus ValueDomain)
Person Completing Form First Name
Item
Person Completing Form First Name
text
C25190 (NCI Thesaurus ObjectClass)
C1550483 (UMLS CUI-1)
C25657 (NCI Thesaurus ObjectClass-2)
C1443235 (UMLS CUI-2)
C25364 (NCI Thesaurus Property)
C25509 (NCI Thesaurus Property-2)
C25191 (NCI Thesaurus ValueDomain)
Person Completing Form Phone
Item
Person Completing Form Phone
text
C25337 (NCI Thesaurus ValueDomain)
C1550483 (UMLS CUI-1)
C25190 (NCI Thesaurus ObjectClass)
C1515258 (UMLS CUI-2)
C25657 (NCI Thesaurus ObjectClass-2)
C25395 (NCI Thesaurus Property)
Data amended
Item
Are data amended (check box if yes, and circle amended items)
boolean
C38148 (NCI Thesaurus ValueDomain)
C0680532 (UMLS CUI-1)
C25474 (NCI Thesaurus ObjectClass)
C25416 (NCI Thesaurus Property)
Item
Reason for MAA-HAI Scan
text
C16502 (NCI Thesaurus ObjectClass)
C0011923 (UMLS 2011AA ObjectClass)
C15731 (NCI Thesaurus ObjectClass-2)
C1134564 (UMLS 2011AA ObjectClass-2)
C28199 (NCI Thesaurus ObjectClass-3)
C0043432 (UMLS 2011AA ObjectClass-3)
C38000 (NCI Thesaurus Property)
C0884358 (UMLS 2011AA Property)
C25638 (NCI Thesaurus ValueDomain)
C0392360 (UMLS 2011AA ValueDomain)
Code List
Reason for MAA-HAI Scan
CL Item
Post-operative Scan (Post-operative scan)
CL Item
To Determine Adequacy Of Hepatic Perfusion For Possible Further Fudr Administration At The Time Of Recurrence Of Hepatic Metastases (To determine adequacy of hepatic perfusion for possible further FUDR administration at the time of recurrence of hepatic metastases)
CL Item
Technical Problems Are Suspected Based On The Volume Of Fluid Administered By The Infusion Pump During Courses Of Fudr (Technical problems are suspected based on the volume of fluid administered by the infusion pump during courses of FUDR)
CL Item
To Evaluate For Inadvertent Extrahepatic Perfusion In The Event Of Severe Chemical Gastritis And/or Upper Gastrointestinal Ulceration (To evaluate for inadvertent extrahepatic perfusion in the event of severe chemical gastritis and/or upper gastrointestinal ulceration)
CL Item
Other (Other reason)
C17649 (NCI Thesaurus)
C0205394 (UMLS 2011AA)
YttriumIntrahepaticInfusionProcedureDiagnosticImagingPerformedSpecify
Item
Other, specify
text
C16502 (NCI Thesaurus ObjectClass)
C0011923 (UMLS 2011AA ObjectClass)
C15731 (NCI Thesaurus ObjectClass-2)
C1134564 (UMLS 2011AA ObjectClass-2)
C28199 (NCI Thesaurus ObjectClass-3)
C0043432 (UMLS 2011AA ObjectClass-3)
C38000 (NCI Thesaurus Property)
C0884358 (UMLS 2011AA Property)
C25685 (NCI Thesaurus ValueDomain)
C1521902 (UMLS 2011AA ValueDomain)

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