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 Start Date field.

DD-MMM-YYYY

Course # ^(d)

Indicates the course number that this concomitant measure / medication started in as derived from the course initiation start date.

5 digits

Day in Course ^(d)

Indicates the day since the beginning of course that this concomitant measure / medication started as derived from the course initiation start date.

5 digits

Start Date ^(m)

Enter the start date of the measure or medication.

DD-MMM-YYYY or MMM-YYYY

Stop Date

Enter the stop date of the measure / medication.

DD-MMM-YYYY or MMM-YYYY

Agent Name

In the case of agents, state the generic name of the medication administered, or, in the case of combinations such as trimethoprim / sulfamethoxazole, state the brand name (i.e., Bactrim).

Use pick list.

Procedure /Measure

If a procedure/measure, state e.g., oxygen administration, pleural tapping, etc.

Use pick list.

Dose ^{(m) (}

Enter the dose of the agent as appropriate.

In the case of combinations such as Bactrim, enter the single dose.
     Ex: Dose 1, Unit tab, schedule bid.


When the schedule is PRN ( For example: taking 2 tabs of Percocet PRN every four hours ) enter the single dose

      Ex: Dose 2, Unit tab, q4hr PRN.

100 characters

UOM

Select the total daily dose units of measurement.

Use pick list.

Schedule

Enter the frequency of medication administration or measure under schedule.

24 characters

Route

Select the route given:
IM - intramuscular
ID - intradermal
IV - intravenous bolus (less than 30 minutes)
IVI - intravenous infusion (greater than 30 minutes, but less than 24 hours)
CIV - continuous intravenous infusion (greater than 24 hours)
IA - intra-arterial
IT - intrathecal
IP - intraperitoneal
IH - intrahepatic
IHI - intrahepatic infusion
SC - subcutaneous
T - topical
PO - oral
RT - radiation

Use pick list.

Reason ^(m)

Select the reason the medication is being administered or why measure done. For example, if Bactrim is being given as a prophylactic, select "pneumocystis prophylaxis".

Use pick list.

CM01

Agent and Procedure are missing.

An Agent or Procedure must be present.

CM02

Both Agent and Procedure are filled.

Agent and Procedure cannot be both selected at the same time.

CM03

Stop Date is before the Start Date.

Stop Date must not be earlier than Start Date.

CM04

Agent entered and Dose and/or Units of Measurement are/is missing.

If Agent is entered, Dose and Unit of Measurement must be present.

CM05

Dose and/or Unit of Measurement entered and Procedure also entered.

If Procedure is entered, Agent, Dose and Unit of Measurement must not be present.

CM06, CM07

Start and/or Stop Date are/is in the future.

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

CM10, CM11

Partial Start Date and/or Stop Date are/is after the first Course Initiation Date.

Partial Start and Stop Dates are only acceptable for baseline measures and/or procedures.

CM12

Dose is not a valid numeric value.

Enter a valid numeric value.

CM1001

Course #

Course number is derived based on the course initiation start dates and the concomitant measure / medication start date.

CM1002

Day in Course

Number of days since the beginning of the course is derived from the course initiation start date and the concomitant measure / medication start date.