Form Structure: Post Discharge/Outpatient Treatment
This form structure is an organized set of data definitions for a form that has not been copyrighted
Title:
Post Discharge/Outpatient Treatment
Short Name:
PostDischOutpatientTreat
Description:
The form structure contains data elements recommended by NINDS to capture the participant's/subject's course of treatment post-discharge. References: NINDS Traumatic Brain Injuryhttps://commondataelements.ninds.nih.gov/TBI.aspx#tab=Data_Standards
Disease:
Traumatic Brain Injury
Organization:
NINDS
Required Program Form:
No
Standardization:
Standard NINDS CDE
Labels:
Form Type:
Clinical Assessment
Version:
1.0
Date Created:
2017-01-24
Owner:
Number of Data Elements:
22
eForms:
N
Logically grouped data elements with defined frequency at which they repeat.
| # | Title | Short Description | Variable Name | Required? | Type |
|---|---|---|---|---|---|
| 1 | GUID | Global Unique ID which uniquely identifies a subject | GUID | Required | CDE |
| 2 | Subject identifier number | An identification number assigned to the participant/subject within a given protocol or a study. | SubjectIDNum | Optional | CDE |
| 3 | Age in years | Value for participant's subject age recorded in years. | AgeYrs | Recommended | CDE |
| 4 | Vital status | Status of participant/subject as alive or dead | VitStatus | Optional | CDE |
| 5 | Visit date | Actual interview or visit date | VisitDate | Recommended | CDE |
| 6 | Site name | The name of the site for the study | SiteName | Recommended | CDE |
| 7 | Days since baseline | The number of days since baseline | DaysSinceBaseline | Optional | CDE |
| 8 | Case control indicator | Indicator of whether subject is in the case or control arm of the study. | CaseContrlInd | Optional | CDE |
| 9 | General notes text | General notes | GeneralNotesTxt | Optional | CDE |
Additional Element Groups
Listed below are your additional element groups.
Form Administration (Appears Up To 1 Time)
| # | Title | Short Description | Variable Name | Required? | Type |
|---|---|---|---|---|---|
| 1 | Language form administration ISO code | Code (ISO 639-2) for the language that was used for CRF/instrument/scale/etc. administration | LangCRFAdministratISOCode | Recommended | CDE |
| 2 | Language form administration ISO code other text | The free-text field related to 'Language used for CRF/instrument/scale/etc. administration ISO code' specifying other text. | LangCRFAdministratISOCodeOTH | Recommended | CDE |
| 3 | Context type | The context to which the questions were answered | ContextType | Recommended | CDE |
| 4 | Context type other text | The free-text related to ContextType specifying other text | ContextTypeOTH | Recommended | CDE |
| 5 | Data source | Source of the data provided on the case report form | DataSource | Recommended | CDE |
| 6 | Data source other text | The free-text field related to Data source specifying other text. Source of the data provided on the case report form | DataSourceOTH | Recommended | CDE |
Post Discharge Outpatient Treatment (Appears Up To 1 Time)
| # | Title | Short Description | Variable Name | Required? | Type |
|---|---|---|---|---|---|
| 1 | Therapy or rehabilitation type | Type of therapy or rehabilitation services received by the participant/subject | TherpyRehabTyp | Optional | CDE |
| 2 | Therapy rehabilitation ICD 9 CM code | ICD-9-CM code that describes the therapy or rehabilitation received by the participant/subject | TherpyRehabICD9CMCd | Optional | CDE |
| 3 | Therapy or rehabilitation frequency | Identified describing the frequency the participant/subject received the therapy or rehabilitation | TherpyRehabFreq | Optional | CDE |
| 4 | Therapy or rehabilitation session duration | Average duration of a therapy or rehabilitation session | TherpyRehabSessnDur | Optional | CDE |
| 5 | Therapy rehabilitation start date time | Date (and time, if applicable and known) on which the therapy or rehabilitation started | TherpyRehabStrtDateTime | Optional | CDE |
| 6 | Therapy rehabilitation end date time | Date (and time, if applicable and known) on which the therapy or rehabilitation ended | TherpyRehabEndDateTime | Optional | CDE |
| 7 | Therapy rehabilitation ongoing indicator | Indicator of whether the therapy or rehabilitation is ongoing | TherpyRehabOngngInd | Optional | CDE |
Keywords
