CCR Clinical Informatics

Visit Date^(m)

Enter the date the form was completed (i.e. the date information was gathered).

DD-MMM-YYYY

Start Date^(m)

Enter the date the patient received the first dose of the new anti-cancer therapy (i.e. the next post-protocol therapy). Partial dates are acceptable when the day is not known.

DD-MMM-YYYY or MMM-YYYY

Stop Date

Enter the date the patient received the last dose of the post-protocol therapy. Partial dates are acceptable when the day is not known. Leave it blank if the treatment is currently being received. 

DD-MMM-YYYY, MMM-YYYY

• MULTIPLE AGENTS

• SINGLE AGENT

• UNKNOWN

Use pick list.

Post-Therapy Followup Agent Name

Select the generic name of the agent that was used.

Note: For standard regimen (multiple agents given as one regimen), enter one record for each agent.

Use pick list.

Total Dose

Enter the total dose of the agent.

8 digits, 3 decimal

Total Dose UOM

Enter the total dose units of measurement.

16 digits

Schedule

Select the schedule on which the agent (or combination) was given. (Optional field)

24 characters

Select the route from the list.

16 characters

Duration^(m)

Enter the duration calculated from the start date/time and stop date/time.

6 digits, 2 decimal

Duration UOM^(m)

Select the units of measurement so that the duration can be derived.
DY - Days
HR - Hours
MN - Minutes
MO - Months
WK - Weeks
SEC- Seconds

Use pick list.

Best Response

Select the best response encountered:
CR - Complete Response 
PD - Progressive Disease
PR - Partial Response
SD - Stable Disease 
UK - Unknown
Leave this field blank if the treatment is ongoing.

Use pick list.