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CDE Detailed Report
This report contains detailed information about the selected CDEs.
Note: If at least one CDE was selected from a copyright- or trademark-protected instrument/scale then all of the CDEs from that instrument/scale are included in this report.
Disease: Cerebral Palsy
Sub-Domain: Physical/Neurological Examination
CRF: Neurological Examination
Item count: 52 (52 distinct CDEs)
CDE ID
CDE Name
Variable Name
Definition / Description
Question Text
Permissible Value
Description
Data Type
Instructions
References
Population
Classification (e.g., Core)
Version #
Version Date
Aliases for Variable Name
CRF Module / Guideline
© or TM
Sub-Domain
Domain
Previous Title
Size
Input Restrictions
Min Value
Max Value
Measurement Type
LOINC ID
SNOMED
caDSR ID
CDISC ID
C19500
Assessment performed date
AssessmentPerformedDate
The date of assessment of the examination being performed.
Date of Exam
  
Date or Date & Time
No instructions available
No references available
Adult;Pediatric
Supplemental
1.0
6/18/2014
Aliases for variable name not defined
Neurological Examination
Physical/Neurological Examination
Assessments and Examinations
  
Free-Form Entry
       
C14431
Mental status examined type
MentlStatExamTyp
Type of mental status assessment performed
Mental assessments
Attention;Working Memory;Recent Memory;Remote Memory;Spontaneous speech;Affect;Language;Language Naming;Language Reading;Language Repetition;Speech;
Attention;Working Memory;Recent Memory;Remote Memory;Spontaneous speech;Affect;Language;Language Naming;Language Reading;Language Repetition;Speech;
Alphanumeric
Answer where applicable Recommended tests are: Attention-forward digit span (6 is normal for adults), Working Memory-reverse digit span (4 is normal for adults), Recent (Episodic) Memory-immediate recall of 3 objects and then recall again after 3-5 minute delay, Remote (Semantic) Memory-either recall of verifiable personal information from the patient's past (i.e. previous addresses or schools) or well-known current events (i.e. naming the Presidents backwards)
No references available
Adult;Pediatric
Supplemental
1.0
10/5/2012
Aliases for variable name not defined
Neurological Examination
Physical/Neurological Examination
Assessments and Examinations
Mental status examined type
 
Multiple Pre-Defined Values Selected
       
C14432
Mental status exam abnormality indicator
MentlStatExamAbnrmlyInd
Whether the mental assessment showed abnormal results
Abnormality Present?
Yes;No;Unknown;
Yes;No;Unknown;
Alphanumeric
Choose only one
No references available
Adult;Pediatric
Supplemental
1.0
10/5/2012
Aliases for variable name not defined
Neurological Examination
Physical/Neurological Examination
Assessments and Examinations
Mental status exam abnormality indicator
 
Single Pre-Defined Value Selected
       
C14433
Cranial nerves global assessment result
CranlNerveGlobAssmtReslt
The condition of Cranial Nerves
Cranial Nerves–global assessment
Normal;Abnormal;Cannot Assess;Other, specify;
Normal;Abnormal;Cannot Assess;Other, specify;
Alphanumeric
Choose only one
No references available
Adult;Pediatric
Supplemental
1.0
10/5/2012
Aliases for variable name not defined
Neurological Examination
Physical/Neurological Examination
Assessments and Examinations
Cranial nerves global assessment result
 
Single Pre-Defined Value Selected
       
C18932
Cranial nerves global assessment other text
CranlNerveGlobAssmtOTH
The free-text field related to 'Cranial nerves global assessment result' specifying other text. The condition of Cranial Nerves
Other, specify
  
Alphanumeric
No instructions available
No references available
Adult;Pediatric
Supplemental
1.0
10/5/2012
Aliases for variable name not defined
Neurological Examination
Physical/Neurological Examination
Assessments and Examinations
 
4000
Free-Form Entry
       
C14434
Cranial nerve abnormal identifier type
CranlNerveAbnrmlIdTyp
The identified cranial nerve that assessed as abnormal.
Cranial Nerve Number
CN II;CN III;CN IV;CN V;CN VI;CN VII;CN VIII;CN IX;CN X;CN XI;CN XII;
Cranial nerve II;Cranial nerve III;Cranial nerve IV;Cranial nerve V;Cranial nerve VI;Cranial nerve VII;Cranial nerve VIII;Cranial nerve IX;Cranial nerve X;Cranial nerve XI;Cranial nerve XII;
Alphanumeric
Record which of the cranial nerves are abnormal and the side. Choose all that apply.
No references available
Adult;Pediatric
Supplemental
3.0
8/28/2013
Aliases for variable name not defined
Neurological Examination
Physical/Neurological Examination
Assessments and Examinations
Cranial nerve abnormal identifier
 
Multiple Pre-Defined Values Selected
       
C02411
Laterality type
LatTyp
Laterality type relative to the anatomic site of the body examined or affected
Laterality
Right;Left;Bilateral;Unknown;
Right;Left;Bilateral;Unknown;
Alphanumeric
Record which of the cranial nerves are abnormal and the side. Choose only one.
No references available
Adult;Pediatric
Supplemental
3.0
8/28/2013
Aliases for variable name not defined
Neurological Examination
Physical/Neurological Examination
Assessments and Examinations
Laterality type
 
Single Pre-Defined Value Selected
       
C18504
Cranial nerves abnormality present text
CranlNerveAbnrmlyPresTxt
The free-text field to explain the abnormality of the cranial nerve identified.
Explain Abnormality
  
Alphanumeric
Indicate which of the following cranial nerves are abnormal.
No references available
Adult;Pediatric
Supplemental
3.0
7/30/2013
Aliases for variable name not defined
Neurological Examination
Physical/Neurological Examination
Assessments and Examinations
 
255
Free-Form Entry
       
C14435
Nystagmus indicator
NystagmusInd
Involuntary movements of the eyeballs; its presence or absence is used to diagnose a variety of neurological and visual disorders
Nystagmus
Yes;No;Cannot Assess;Unknown;
Yes;No;Cannot Assess;Unknown;
Alphanumeric
Specify type, if yes
No references available
Adult;Pediatric
Supplemental
1.0
10/5/2012
Aliases for variable name not defined
Neurological Examination
Physical/Neurological Examination
Assessments and Examinations
Nystagmus indicator
 
Single Pre-Defined Value Selected
       
C14436
Nystagmus type
NystagmusTyp
Type of involuntary movement of the eyeballs; its presence or absence is used to diagnose a variety of neurological and visual disorders
Type of nystagmus
Physiologic;Abnormal;Other, specify;
Physiologic;Abnormal;Other, specify;
Alphanumeric
Enter type of nystagmus; physiological nystagmus is normal nystagmus (i.e. a few beats at end gaze)
No references available
Adult;Pediatric
Supplemental
1.0
10/5/2012
Aliases for variable name not defined
Neurological Examination
Physical/Neurological Examination
Assessments and Examinations
Nystagmus type
 
Single Pre-Defined Value Selected
       
C18933
Nystagmus other text
NystagmusOTH
The free-text field related to 'Nystagmus type' specifying other text. Type of involuntary movement of the eyeballs; its presence or absence is used to diagnose a variety of neurological and visual disorders
Other, specify
  
Alphanumeric
Enter type of nystagmus; physiological nystagmus is normal nystagmus (i.e. a few beats at end gaze)
No references available
Adult;Pediatric
Supplemental
1.0
10/5/2012
Aliases for variable name not defined
Neurological Examination
Physical/Neurological Examination
Assessments and Examinations
 
4000
Free-Form Entry
       
C18503
Assessment unable text
AssmtUnableTxt
The free-text field to explain why there was no assessment of nystagmus performed.
Cannot access, explain
  
Alphanumeric
No instructions available
No references available
Adult;Pediatric
Supplemental
3.0
7/30/2013
Aliases for variable name not defined
Neurological Examination
Physical/Neurological Examination
Assessments and Examinations
 
255
Free-Form Entry
       
C14438
Motor exam global abnormality present indicator
MotorExamGloblAbnrmlyPresInd
Global assessment whether an abnormality was present following the motor exam.
Abnormality present?
Yes;No;Cannot Assess;Unknown;
Yes;No;Cannot Assess;Unknown;
Alphanumeric
Choose one for each global assessment type.
No references available
Adult;Pediatric
Supplemental
3.0
8/28/2013
Aliases for variable name not defined
Neurological Examination
Physical/Neurological Examination
Assessments and Examinations
Motor exam global assessment abnormality indicator
 
Single Pre-Defined Value Selected
       
C14439
Motor exam global assessment abnormality type
MotorExamGloblAbnrmlyAssmtTyp
Global assessment abnormality type found during the motor exam
If Abnormal, indicate type
Abnormal and symmetric;Abnormal and asymmetric;Abnormal - Increased;Abnormal - Decreased;Abnormal and bilateral;Abnormal and unilateral;
Abnormal and symmetric;Abnormal and asymmetric;Abnormal - Increased;Abnormal - Decreased;Abnormal and bilateral;Abnormal and unilateral;
Alphanumeric
If the global assessment found an abnormality, then record the abnormality type
No references available
Adult;Pediatric
Supplemental
3.0
8/28/2013
Aliases for variable name not defined
Neurological Examination
Physical/Neurological Examination
Assessments and Examinations
Motor exam global assessment abnormality type
 
Single Pre-Defined Value Selected
       
C14442
Muscle bulk assessment abnormality type
MuscBulkAbnrmlyAssmtTyp
The muscle bulk abnormality type
If abnormal, indicate type
Abnormal and symmetric;Abnormal and asymmetric;Abnormal - Increased;Abnormal - Decreased;Abnormal and bilateral;Abnormal and unilateral;
Abnormal and symmetric;Abnormal and asymmetric;Abnormal - Increased;Abnormal - Decreased;Abnormal and bilateral;Abnormal and unilateral;
Alphanumeric
Choose one.
No references available
Adult;Pediatric
Supplemental
3.0
8/28/2013
Aliases for variable name not defined
Neurological Examination
Physical/Neurological Examination
Assessments and Examinations
Muscle bulk assessment abnormality type
 
Single Pre-Defined Value Selected
       
C14441
Muscle bulk assessment abnormality indicator
MuscBulkAbnrmlyAssmtInd
Whether the muscle bulk assessment found any abnormalities
Abnormality Present?
Yes;No;Cannot Assess;Unknown;
Yes;No;Cannot Assess;Unknown;
Alphanumeric
No instructions available
No references available
Adult;Pediatric
Supplemental
3.0
8/28/2013
Aliases for variable name not defined
Neurological Examination
Physical/Neurological Examination
Assessments and Examinations
Muscle bulk assessment abnormality indicator
 
Single Pre-Defined Value Selected
       
C14440
Muscle bulk assessment anatomic site
MuscBulkAssmtAntmicSite
Anatomic location of the muscle bulk exam as part of the motor examination.
Muscle Bulk - global assessment
Right upper extremity;Left upper extremity;Right lower extremity;Left lower extremity;
Right upper extremity (RUE);Left upper extremity (LUE);Right lower extremity (RLE);Left lower extremity (LLE);
Alphanumeric
No instructions available
No references available
Adult;Pediatric
Supplemental
3.0
8/28/2013
Aliases for variable name not defined
Neurological Examination
Physical/Neurological Examination
Assessments and Examinations
Muscle bulk assessment anatomic site
 
Single Pre-Defined Value Selected
       
C18935
Muscle bulk assessment abnormality other text
MuscBulkAbnrmlyAssmtOTH
The free-text field related to 'Muscle bulk assessment abnormality type' specifying other text. The muscle bulk abnormality type
Other, specify
  
Alphanumeric
No instructions available
No references available
Adult;Pediatric
Supplemental
3.0
8/28/2013
Aliases for variable name not defined
Neurological Examination
Physical/Neurological Examination
Assessments and Examinations
 
4000
Free-Form Entry
       
C14443
Muscle tone assessment anatomic site
MuscToneAssmtAntmicSite
Anatomic location of the muscle tone as part of the motor examination.
Muscle Tone - global assessment
Right upper extremity;Left upper extremity;Right lower extremity;Left lower extremity;Truncal tone;
Right upper extremity (RUE);Left upper extremity (LUE);Right lower extremity (RLE);Left lower extremity (LLE);Truncal tone;
Alphanumeric
Evaluate all extremities. Truncal tone – is recommended for pediatric studies only.
No references available
Adult;Pediatric
Supplemental
3.0
8/28/2013
Aliases for variable name not defined
Neurological Examination
Physical/Neurological Examination
Assessments and Examinations
Muscle tone assessment anatomic site
 
Single Pre-Defined Value Selected
       
C14444
Muscle tone assessment abnormality indicator
MuscToneAbnrmlyAssmtInd
Whether the muscle tone assessment found any abnormalities
Abnormality Present?
Yes;No;Not assessed;Unknown;Cannot Assess;
Yes;No;Not assessed;Unknown;Cannot Assess;
Alphanumeric
Choose one for each anatomic site.
No references available
Adult;Pediatric
Supplemental
3.0
8/28/2013
Aliases for variable name not defined
Neurological Examination
Physical/Neurological Examination
Assessments and Examinations
Muscle tone assessment abnormality indicator
 
Single Pre-Defined Value Selected
       
C18936
Muscle tone assessment abnormality other text
MuscToneAbnrmlyAssmtOTH
The free-text field related to 'Muscle tone assessment abnormality type' specifying other text. The muscle tone abnormality type
Other, specify
  
Alphanumeric
No instructions available
No references available
Adult;Pediatric
Supplemental
3.0
8/28/2013
Aliases for variable name not defined
Neurological Examination
Physical/Neurological Examination
Assessments and Examinations
 
4000
Free-Form Entry
       
C14445
Muscle tone assessment abnormality type
MuscToneAbnrmlyAssmtTyp
The muscle tone abnormality type
If Abnormal, indicate type
Abnormal - Decreased;Abnormal - Increased;Abnormal and bilateral;Abnormal and unilateral;Abnormal–Hypertonia;Abnormal–Hypotonia;Other, specify;
Abnormal - Decreased;Abnormal - Increased;Abnormal and bilateral;Abnormal and unilateral;Abnormal–Hypertonia;Abnormal–Hypotonia;Other, specify;
Alphanumeric
Choose one
No references available
Adult;Pediatric
Supplemental
3.0
8/28/2013
Aliases for variable name not defined
Neurological Examination
Physical/Neurological Examination
Assessments and Examinations
Muscle tone assessment abnormality type
 
Single Pre-Defined Value Selected
       
C14446
Muscle strength assessment anatomic site
MuscStrAssmtAntmicSite
Anatomic location of the muscle strength as part of the motor examination.
Muscle Strength - global assessment
Right upper extremity;Left upper extremity;Right lower extremity;Left lower extremity;
Right upper extremity (RUE);Left upper extremity (LUE);Right lower extremity (RLE);Left lower extremity (LLE);
Alphanumeric
Evaluate all extremities.
No references available
Adult;Pediatric
Supplemental
3.0
8/28/2013
Aliases for variable name not defined
Neurological Examination
Physical/Neurological Examination
Assessments and Examinations
Muscle strength assessment anatomic site
 
Single Pre-Defined Value Selected
       
C14447
Muscle strength abnormality assessment indicator
MuscStrAbnrmlyAssmtInd
Whether the muscle strength assessment found any abnormalities
Abnormality present?
Yes;No;Not assessed;Unknown;Cannot Assess;
Yes;No;Not assessed;Unknown;Cannot Assess;
Alphanumeric
Choose one for each anatomic site
No references available
Adult;Pediatric
Supplemental
3.0
8/28/2013
Aliases for variable name not defined
Neurological Examination
Physical/Neurological Examination
Assessments and Examinations
Muscle strength assessment abnormality indicator
 
Single Pre-Defined Value Selected
       
C14448
Muscle strength abnormality assessment type
MuscStrAbnrmlyAssmtTyp
The muscle strength abnormality type
If Abnormal, indicate type
Abnormal - Decreased;Abnormal - Increased;Abnormal and bilateral;Abnormal and unilateral;Abnormal–Hypertonia;Abnormal–Hypotonia;Other, specify;
Abnormal - Decreased;Abnormal - Increased;Abnormal and bilateral;Abnormal and unilateral;Abnormal–Hypertonia;Abnormal–Hypotonia;Other, specify;
Alphanumeric
Choose one
No references available
Adult;Pediatric
Supplemental
3.0
8/28/2013
Aliases for variable name not defined
Neurological Examination
Physical/Neurological Examination
Assessments and Examinations
Muscle strength assessment abnormality type
 
Single Pre-Defined Value Selected
       
C18937
Muscle strength abnormality assessment other text
MuscStrAbnrmlyAssmtOTH
The free-text field related to 'Muscle strength abnormality assessment type' specifying other text. The muscle strength abnormality type
Other, specify
  
Alphanumeric
No instructions available
No references available
Adult;Pediatric
Supplemental
3.0
8/28/2013
Aliases for variable name not defined
Neurological Examination
Physical/Neurological Examination
Assessments and Examinations
 
4000
Free-Form Entry
       
07-21-2019
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