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Contents

Purpose

The MD Anderson Symptom Inventory (MDASI) is a survey that patients will complete at time of tumor imaging to assess the severity of their brain tumor-related symptoms or spinal tumor and the impact these symptoms have on their daily functioning. The MDASI-Simplified form is completed to indicate if MDASI- BT or MDASI-SP forms were completed; to capture the reason if the forms were not completed; Which MDASI Instrument was completed; Date of the completion of the form and who filled the survey.


MDASI-Simplified eCRF

 

Field Name

Description / Instructions

Format

Visit Date(m)

Enter the date the eCRF was completed

DD-MMM-YYYY

 
Was MDASI instrument completed?

Indicate whether the MDASI instrument completed:
YES - Yes
NO - No
NOT APPLICABLE - Not Applicable

Use pick list.

If no, why was the MDASI instrument not completed?

Indicate the reason why the MD Anderson Symptom Inventory was not completed:
ADMINISTRATOR ERROR - Administrator Error

PATIENT REFUSED - Patient Refused
PATIENT UNABLE TO COMPLETE DUE TO SYMPTOMS - Patient Unable to Complete Due To Symptoms

Use pick list.

Which MDASI instrument did the patient complete?Indicate the text term that represents the name of the MD Anderson Symptom Inventory instrument completed by the patient:
MDASI-BT - MD Anderson Symptom Inventory - Brain Tumor
MDASI-SP -
MD Anderson Symptom Inventory - Spine Tumor

Use pick list.

Date completed by patient?

Enter the date the MDASI instrument was completed by the patient

DD-MMM-YYYY

Who filled out the survey?Optional field. If this information is known, indicate the text term that describes the person who filled out the MD Anderson Symptom Inventory instrument:
PATIENT - INDEPENDENTLY - Patient Completed Independently

PATIENT WITH CAREGIVER ASSISTANCE TO ENTER DATA - Patient With Caregiver Assistance

Use pick list.

Legend:  (m) RDC mandatory 

Validations

Code

Description

Resolutions

 

 

 

 

Last updated by Blackburn, Katie (NIH/NCI) [C] on Apr 18, 2017