CCR Clinical Informatics

Visit Date

The Visit Date is optional on this case report form. Hit the "Tab" key to leave it empty and move to the Date of Vitals field.

DD-MMM-YYYY

Course #^(d)

Indicates the course number the vital signs are related to based on their date and time.

5 digits

Day in Course^(d)

Indicates the day since the beginning of course the vital signs are related to based on their date and time.

5 digits

Date of Vitals^(m)

Enter the date the vital signs were taken.

DD-MMM-YYYY

Time

Enter the time the vital signs were taken.

HH(24):MM

Notes

200 characters

Performance Status (Karnofsky)

Select a value from the Karnofsky performance status scale.
0 - Dead
10 - Moribund
20 - Very Sick
30 - Hospitalized
40 - Disabled
50 - Frequent Assistance
60 - Occasional Assistance
70 - Self Care
80 - Effort
90 - Able
100 - Normal

Use pick list.

Status (Zubrod)

Select a value from the Zubrod/ECOG performance status scale.
0. Asymptomatic
1. Symptomatic, fully ambulatory
2. Symptomatic, in bed less than 50% of day
3. Symptomatic, in bed more than 50% of the day, but not bedridden
4. Bedridden

Use pick list.

Performance Status (Lansky)

Select a value from the Lansky performance status scale.
0 - Unresponsive
10 - No play; does not get out of bed
20 - Often sleeping; play entirely limited to very passive activities
30 - In bed; needs assistance even for quiet play
40 - Mostly in bed; participates in quiet activities
50 - Gets dressed but lies around much of the day; no active play; able to participate in all quiet play
60 - Up and around; but minimal active play; keeps busy with quieter activities
70 - Both greater restriction of and less time spent in play activity
80 - Active; but tires more quickly
90 - Minor restrictions in physically strenuous activity
100 - Fully active, normal

Use pick list.

Body Weight^(m)

Enter the patient's weight only in kilograms. Use decimal places only for patients under 10kg. See Appendix 1 for conversion factors.

5 digits and 2 decimals

Height^(m)

Enter the patient's height only in centimeters, to one decimal place. See Appendix 1 for conversion factors.

5 digits and 2 decimals

BSA^(m)

Enter the patient's body surface area in m2 (to two decimal places) if needed for the calculation of study medication dose level. A nomogram for children's and adult's body surface area calculation can be found in Appendix 1.
The following simple approximation may be used for persons of "normal" height and weight:

5 digit and 3 decimals

Temperature

Enter the patient's temperature only in Celsius, to one decimal place. See Appendix 1 for conversion factors.

3 digits and 1 decimal

Pulse

Enter the patient's pulse rate.

3 digits

Respiration Rate

Enter the patient's respiration rate.

3 digits

Systolic Blood Pressure

Enter the patient's systolic blood pressure.

8 digits and 3 decimals

Diastolic Blood Pressure

Enter the patient's diastolic blood pressure.

8 digits and 3 decimals

Pulse Oximetry

Enter the patient's pulse oximetry reading.

3 digits and 2 decimals

VIT01

Systolic Blood Pressure is less than Diastolic Blood Pressure.

Systolic Blood Pressure must be greater than Diastolic Blood Pressure.

VIT02

Two Vital Signs entries have the same Date and Time.

Correct the date and/or time.

VIT03

Entered BSA is not within 10% accuracy of the calculated BSA using the MIS formula.

Correct the BSA.
The MIS BSA formula is: BSA (m²) = Height(cm)^0.725 x Weight(kg)^0.425 / 139.315

VIT04

Entered BSA is not within 10% accuracy of the calculated BSA using the Mosteller formula.

Correct the BSA.
The Mosteller BSA formula is: BSA (m²) = ( Height(cm) x Weight(kg) / 3600 )^½

VIT05

Vitals Date is in the future.

Enter a date that is equal to or prior to the current date.

VIT06, VIT07,
VIT08, VIT09,
VIT10, VIT11,
VIT12, VIT13

Height, Weight, BSA, Temperature, Pulse, Respiration Rate, Systolic and/or Diastolic Blood Pressure are/is less than zero.

Height, Weight, BSA, Temperature, Pulse, Respiration Rate, Systolic Blood Pressure and Diastolic Blood Pressure must be greater than zero.

VIT14

Pulse Oximetry is out of range.

Pulse Oximetry must be an integer number between 0 and 100.

VIT15

Vitals (on cycle sections) have Date of Vitals outside the range of the cycle start and stop date.

VIT1001

Course #

Course number is derived based on the course initiation start dates and the vital signs date.

VIT1002

Day in Course

Number of days since the beginning of the course is derived from the course initiation start date and the vital signs date.