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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: General (For all diseases)
Sub-Domain: Physical/Neurological Examination
CRF: Physical Exam
Item count: 9 (9 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
C01010
Physical exam date and time
PhysExamDateTime
Date (and time if applicable and known) physical exam was performed
Date of Exam
  
Date or Date & Time
Record the date(and time) the physical exam was performed. The date/time should be recorded to the level of granularity known (e.g., year, year and month, complete date plus hours and minutes, etc.) and in the format acceptable to the study database.
No references available
Adult;Pediatric
Supplemental
3.0
8/28/2013
EVAL_DT
Physical Exam
Physical/Neurological Examination
Assessments and Examinations
Physical exam date and time
 
Free-Form Entry
     
2004170
 
C01015
Physical exam performed indicator
PhysExamPerfrmdInd
Indicator of whether a physical exam was performed on the participant/subject
Was a physical exam performed on the participant/subject?
Yes;No;Unknown;
Yes;No;Unknown;
Alphanumeric
Choose one. Specify whether or not a physical exam was performed on the participant/subject.
No references available
Adult;Pediatric
Supplemental
3.0
7/25/2013
PT_PHYS_IND2
Physical Exam
Physical/Neurological Examination
Assessments and Examinations
Physical exam performed indicator
 
Single Pre-Defined Value Selected
     
2201750
 
C00312
Body system category
BodySysCat
Category or grouping used in the comprehensive assessment of a participant/subject, which includes a subjective history taking component as well as an objective based structured interview and physical examination of all the body systems.
Body System
Allergic/Immunologic;Cardiovascular;Constitutional symptoms (e.g., fever, weight loss);Dermatological;Ears, Nose, Mouth, Throat;Endocrine;Eyes;Gastrointestinal;Gastrointestinal/Abdominal;Genitourinary;Gynecologic/Urologic/ Renal;Hematologic/Lymphatic;Hepatobiliary;Integumentary (skin and/or breast);Musculoskeletal;Musculoskeletal (separate from ALS exam);Neurological;Neurologic/CNS;Neurological (separate from ALS exam);Oncologic;Psychiatric;Pulmonary;Respiratory;Other, specify:;
Allergic/Immunologic;Cardiovascular;Constitutional symptoms (e.g., fever, weight loss);Dermatological;Ears, Nose, Mouth, Throat;Endocrine;Eyes;Gastrointestinal;Gastrointestinal/Abdominal;Genitourinary;Gynecologic/Urologic/ Renal;Hematologic/Lymphatic;Hepatobiliary;Integumentary (skin and/or breast);Musculoskeletal;Musculoskeletal (separate from ALS exam);Neurological;Neurologic/CNS;Neurological (separate from ALS exam);Oncologic;Psychiatric;Pulmonary;Respiratory;Other, specify:;
Alphanumeric
Each body system is pre-populated on the case report form.
Review of Symptoms from Centers for Medicare and Medicaid Services https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/downloads/eval_mgmt_serv_guide-ICN006764.pdf
Adult;Pediatric
Supplemental
3.0
7/25/2013
Aliases for variable name not defined
Physical Exam
Physical/Neurological Examination
Assessments and Examinations
Body system category
 
Single Pre-Defined Value Selected
     
2002895
 
C18666
Body system other text
BodySysOTH
The free-text field related to 'Body system category' specifying other text. Category or grouping used in the comprehensive assessment of a participant/subject, which includes a subjective history taking component as well as an objective based structured
Other, specify
  
Alphanumeric
Each body system is pre-populated on the case report form.
Review of Symptoms from Centers for Medicare and Medicaid Services https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/downloads/eval_mgmt_serv_guide-ICN006764.pdf
Adult;Pediatric
Supplemental
1.0
5/27/2014
Aliases for variable name not defined
Physical Exam
Physical/Neurological Examination
Assessments and Examinations
 
4000
Free-Form Entry
     
2002895
 
C01012
Physical exam body system result type
PhysExamBodySysResltTyp
Assessment result of each body system examined
Result
Abnormal;Normal;Not assessed;
Abnormal;Normal;Not assessed;
Alphanumeric
Choose one. Indicate whether each body system examined had any abnormal findings.
No references available
Adult;Pediatric
Supplemental
3.0
7/25/2013
FNG_RSLT_STAT
Physical Exam
Physical/Neurological Examination
Assessments and Examinations
Physical exam body system result type
 
Single Pre-Defined Value Selected
     
2821383
 
C01013
Physical exam description text
PhysExamDescripTxt
Free text field to describe the abnormality in a specific body system or an explanation of why the body system was not examined
Describe Abnormality or Comment if Body System is Not Examined
  
Alphanumeric
Provide a description of each abnormal result found during the physical exam, or provide an explanation of why the body system was not examined. See the data dictionary for additional information on coding the abnormality using the Systemized Nomenclature of Medicine-Clinical Terms(SNOMED CT).
SNOMED CT CODES - Problem List (http://www.nlm.nih.gov/research/umls/Snomed/core_subset.html)
Adult;Pediatric
Supplemental
3.0
7/25/2013
PT_ABN_PHYSEX_SPEC
Physical Exam
Physical/Neurological Examination
Assessments and Examinations
Physical exam description text
255
Free-Form Entry
     
2201880
 
C01028
Physical exam condition SNOMED CT code
PhysExamCondSNOMEDCTcode
Medical condition/disease found during the physical examination of the participant/subject. Systematized Nomenclature of Medicine-Clinical Terms (SNOMED CT)
Describe Abnormality or Comment if Body System is Not Examined
  
Alphanumeric
Code the description of each abnormal result found during the physical exam using the Systematized Nomenclature of Medicine-Clinical Terms (SNOMED CT).
SNOMED CT CODES - Problem List (http://www.nlm.nih.gov/research/umls/Snomed/core_subset.html)
Adult;Pediatric
Supplemental
3.0
8/28/2013
Aliases for variable name not defined
Physical Exam
Physical/Neurological Examination
Assessments and Examinations
Physical exam condition SNOMED CT code
255
Free-Form Entry
       
C01014
Physical exam abnormality significance type
PhysExamAbnrmlySignfcnceTyp
An indication if the physical exam abnormality in a specific body system is clinically significant
If Abnormality, clinically significant?
Clinically Significant;Not Clinically Significant;
Clinically Significant;Not Clinically Significant;
Alphanumeric
Choose one. If the body system had an abnormal finding, record whether the abnormality is Clinically Significant. Any Abnormal, Clinically Significant finding at screening should be recorded on the Medical History as well.
No references available
Adult;Pediatric
Supplemental
3.0
7/25/2013
PE_ABNORM_CLINC_SIG
Physical Exam
Physical/Neurological Examination
Assessments and Examinations
Physical exam abnormality significance type
 
Single Pre-Defined Value Selected
     
3180087
 
C00023
Hand preference type
HandPrefTyp
Hand which the participant/subject uses predominantly, not necessarily the hand he/she writes with exclusively.
Hand preference
Left hand;Right hand;Both hands;Unknown;
Left hand;Right hand;Both hands;Unknown;
Alphanumeric
Choose one - the hand which the participant/subject uses predominantly, not necessarily the hand the participant/subject writes with exclusively
No references available
Adult;Pediatric
Supplemental
3.0
7/25/2013
Aliases for variable name not defined
Physical Exam
Physical/Neurological Examination
Assessments and Examinations
Hand preference type
 
Single Pre-Defined Value Selected
     
2180147
 
12-09-2018
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