CDE Detailed Report
Subdomain Name: Physical/Neurological Examination
CRF: Physical Examination
Displaying 1 - 9 of 9
| CDE ID | CDE Name | Variable Name | Definition | Short Description | Question Text | Permissible Values | Description | Data Type | Disease Specific Instructions | Disease Specific Reference | Population | Classification (e.g., Core) | Version Number | Version Date | CRF Name (CRF Module / Guidance) | Subdomain Name | Domain Name | Size | Input Restrictions | Min Value | Max Value | Measurement Type | External Id Loinc | External Id Snomed | External Id caDSR | External Id CDISC |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| C18666 | Body system category other text | BodySysCatOTH | 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 | 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 |
Enter all significant medical history items, including surgeries, EXCEPT the problem/condition that is the focus of this study. Use only one line per description. Each body system is pre-populated on the case report form. Record the physical exam results for each. |
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 | 1.10 | 2023-11-07 08:40:35.0 | Physical Examination | Physical/Neurological Examination | Assessments and Examinations | 4000 |
Free-Form Entry |
2002895 | ||||||||
| C00023 | Hand preference type | HandPrefTyp | Hand which the participant/subject uses predominantly, not necessarily the hand he/she writes with exclusively | Hand which the participant/subject uses predominantly, not necessarily the hand he/she writes with exclusivel | 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 | Core | 3.00 | 2013-07-25 08:54:08.2 | Physical Examination | Physical/Neurological Examination | Assessments and Examinations |
Single Pre-Defined Value Selected |
2180147 | |||||||
| 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 | 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 system | Body System | Allergic/Immunologic;Cardiovascular;Constitutional symptoms (e.g., fever, weight loss);Ears, Nose, Mouth, Throat;Endocrine;Eyes;Gastrointestinal;Integumentary (skin and/or breast);Musculoskeletal;Neurological;Psychiatric;Respiratory | Allergic/Immunologic;Cardiovascular;Constitutional symptoms (e.g., fever, weight loss);Ears, Nose, Mouth, Throat;Endocrine;Eyes;Gastrointestinal;Integumentary (skin and/or breast);Musculoskeletal;Neurological;Psychiatric;Respiratory | Alphanumeric |
Enter all significant medical history items, including surgeries, EXCEPT the problem/condition that is the focus of this study. Use only one line per description. Each body system is pre-populated on the case report form. Record the physical exam results for each. |
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 | 3.00 | 2013-07-25 08:54:08.2 | Physical Examination | Physical/Neurological Examination | Assessments and Examinations |
Single Pre-Defined Value Selected |
2002895 | |||||||
| C01010 | Physical exam date and time | PhysExamDateTime | Date (and time if applicable and known) physical exam was performed | Date (and time if applicable and known) physical exam was performed | Date of Exam: | Date or Date & Time |
Record the date/time according to the ISO 8601, the International Standard for the representation of dates and times (http://www.iso.org/iso/home.html). 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.). |
No references available | Adult;Pediatric | Supplemental | 3.00 | 2013-08-28 16:08:00.453 | Physical Examination | Physical/Neurological Examination | Assessments and Examinations |
Free-Form Entry |
2004170 | |||||||||
| C01012 | Physical exam body system result type | PhysExamBodySysResltTyp | Assessment result of each body system examined | 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 | 3.00 | 2013-07-25 08:54:08.2 | Physical Examination | Physical/Neurological Examination | Assessments and Examinations |
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 | 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 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 | 3.00 | 2013-07-25 08:54:08.2 | Physical Examination | Physical/Neurological Examination | Assessments and Examinations | 255 |
Free-Form Entry |
2201880 | ||||||||
| C01014 | Physical exam abnormality significance type | PhysExamAbnrmlySignfcnceTyp | An indication if the physical exam abnormality in a specific body system is clinically significant | 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 | 3.00 | 2013-07-25 08:54:08.2 | Physical Examination | Physical/Neurological Examination | Assessments and Examinations |
Single Pre-Defined Value Selected |
3180087 | |||||||
| C01015 | Physical exam performed indicator | PhysExamPerfrmdInd | Indicator of whether a physical exam was performed on the participant/subject | 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 | 3.00 | 2013-07-25 08:54:08.2 | Physical Examination | Physical/Neurological Examination | Assessments and Examinations |
Single Pre-Defined Value Selected |
2201750 | |||||||
| 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) | 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 | 3.00 | 2013-08-28 16:08:00.453 | Physical Examination | Physical/Neurological Examination | Assessments and Examinations | 255 |
Free-Form Entry |
