CDE Detailed Report

Disease: system
Subdomain Name: Physical Examinations
CRF: files

Displaying 101 - 126 of 126
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
C06406 Hypohidrosis past three months status HypohdrPstThreeMoStatus Status of whether the subject had hypohidrosis after spinal cord lesion within the last three months. Hypohidrosis is defined as a loss of ability to sweat and is normally seen below the level of injury due to disruption of sympathetic outflow. Hypohidrosis may be total or partial Status of whether the subject had hypohidrosis after spinal cord lesion within the last three months. Hypohidrosis is defined as a loss of ability to sweat and is normally seen below the level of injury due to disruption of sympathetic outflow. Hypohidrosis may be total or partia Thermoregulation history after spinal cord lesion within the last three months Hypohidrosis Above lesion;Below lesion;Unknown Above lesion;Below lesion;Unknown Alphanumeric

Choose one

 Karlsson AK, Krassioukov A, Alexander MS, Donovan W, Biering-SØrensen F. International spinal cord injury skin and thermoregulation function basic data set. Spinal Cord. 2012 Jul;50(7):512-6. doi: 10.1038/sc.2011.167. Adult;Pediatric Supplemental 3.00 2013-07-17 09:26:36.973 Clinical Assessment Physical Examinations Assessments and Examinations

Single Pre-Defined Value Selected
C02411 Laterality type LatTyp Laterality type relative to the anatomic site of the body examined or affected Laterality type relative to the anatomic site of the body examined or affected Pain locations sites Left;Right Left;Right Alphanumeric Adult;Pediatric Supplemental 3.00 2013-08-28 16:08:00.453 Clinical Assessment Physical Examinations Assessments and Examinations

Single Pre-Defined Value Selected
C06110 Pneumonia episode treat antibiotic past year number PnmnaEpsdTrtAntibtcPstYrNum Number of pneumonia episodes treated with antibiotics occurring after the spinal cord lesion and within the last year Number of pneumonia episodes treated with antibiotics occurring after the spinal cord lesion and within the last year Number of episodes treated with antibiotics Numeric Values

Only answer if there is a history of pneumonia after spinal cord lesion and within the last year. If number of episodes is unknown then code 999 (999 = Unknown).

 Biering-SØrensen F, Krassioukov A, Alexander MS, Donovan W, Karlsson AK, Mueller G, Perkash I, William Sheel A, Wecht J, Schilero GJ.International Spinal Cord Injury Pulmonary Function Basic Data Set. Spinal Cord. 2012 Jun; 50(6):418-21. Adult;Pediatric Supplemental 3.00 2013-07-17 09:26:36.973 Clinical Assessment Physical Examinations Assessments and Examinations

Free-Form Entry
C19356 Thermoregulation past three months reported type ThermoPastThreeMnthRepTyp The type of reported mechanism to regulate body temperature in the past three months The type of reported mechanism to regulate body temperature in the past three month Thermoregulation history after spinal cord lesion within the last three months Hyperthermia;Hypothermia;Hyperhidrosis;Hypohidrosis;Other, specify;None of the above;Unknown Hyperthermia;Hypothermia;Hyperhidrosis;Hypohidrosis;Other, specify;None of the above;Unknown Alphanumeric

Choose one
Hyperthermia, usually defined as rectal temperature above 38.4 C, as well as hypothermia, defined as rectal temperature below 35 C may be caused by an infection. Hyper and hypothermia may also be caused by non infectious reasons as exercise or by increased or decreased environmental temperature; the individual with spinal cord lesion is prone tobe poikilothermic. Hyperhidrosis is defined as excessive sweating above or below level of injury in the absence of increased ambient temperature. Hyperhidrosis may be a sign of an ongoing pathological process such as syringomyelia, autonomic dysreflexia, or dyspepsia or may accompany micturition and defecation. Hyperhidrosis may also be present without any known cause. Hypohidrosis is defined as a loss of ability to sweat and is normally seen below the level of injury due to disruption of sympathetic outflow. Hypohidrosis may be total or partial. Other thermoregulatory (for example subjective feeling of coldness) and sudomotor findings may be present and should be specified.

 Karlsson AK, Krassioukov A, Alexander MS, Donovan W, Biering-SØrensen F. International spinal cord injury skin and thermoregulation function basic data set. Spinal Cord. 2012 Jul;50(7):512-6. doi: 10.1038/sc.2011.167. Adult;Pediatric Supplemental 1.00 2014-06-12 12:12:56.0 Clinical Assessment Physical Examinations Assessments and Examinations

Single Pre-Defined Value Selected
C06239 Constipation lifestyle alteration past three months scale ConstptnLifstylAltPstThrMoScl The scale that assesses lifestyle alteration due to constipation within the last three months. The scale that assesses lifestyle alteration due to constipation within the last three months. Lifestyle alteration due to constipation (within the last three months): Lifestyle altered each day;Lifestyle altered at least once per week but not every day;Lifestyle altered more than once per month but not every week;Lifestyle altered once per month;Lifestyle altered less than once per month;Lifestyle not altered;Not applicable;Unknown Lifestyle altered each day;Lifestyle altered at least once per week but not every day;Lifestyle altered more than once per month but not every week;Lifestyle altered once per month;Lifestyle altered less than once per month;Lifestyle not altered;Not applicable;Unknown Alphanumeric

Choose one. This variable only covers altered lifestyle due constipation related symptoms including difficult bowel evacuation. Examples may by avoidance of social activities, traveling etc.

 Krogh K, Perkash I, Stiens SA, Biering-SØrensen F. International bowel function extended spinal cord injury data set. Spinal Cord. 2009 Mar;47(3):235-41. Adult;Pediatric Supplemental 3.00 2013-07-17 09:26:36.973 Clinical Assessment Physical Examinations Assessments and Examinations

Single Pre-Defined Value Selected
C06439 Fracture date FractrDate Date (and time, if applicable and known) the fracture occurred at each site Date (and time, if applicable and known) the fracture occurred at each site Date of fracture 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.).

 Biering-SØrensen F, Burns AS, Curt A, Harvey LA, Jane Mulcahey M, Nance PW, Sherwood AM, Sisto SA. International spinal cord injury musculoskeletal basic data set. Spinal Cord. 2012 Nov;50(11):797-802; doi: 10.1038/sc.2012.102. Adult;Pediatric Supplemental 3.00 2013-07-17 09:26:36.973 Clinical Assessment Physical Examinations Assessments and Examinations

Free-Form Entry
C06195 Constipating agent fecal incontinence drug last four week indicator ConAgFeclInconLstFourWkInd Indicator related to whether a constipating agent or drugs against fecal incontinence were used in the last four weeks Indicator related to whether a constipating agent or drugs against fecal incontinence were used in the last four weeks Constipating agents/drugs against fecal incontinence Yes;No;Unknown Yes;No;Unknown Alphanumeric

(within the last four weeks)

 Krogh K, Perkash I, Stiens SA, Biering-SØrensen F. International bowel function basic spinal cord injury data set. Spinal Cord. 2009 Mar;47(3):230-4 Adult;Pediatric Supplemental 3.00 2013-07-17 09:26:36.973 Clinical Assessment Physical Examinations Assessments and Examinations

Single Pre-Defined Value Selected
C21630 Instability assessment method type InstabAssmntMethdTyp Type of method(s) used to determine the presence of hip instability Type of method(s) used to determine the presence of hip instabilit If yes, method of assessment Observation;Palpation;Radiographs Observation;Palpation;Radiographs Alphanumeric

(Check all that apply)

 O'Brien MF. (2005). Spinal Deformity Study Group Radiographic Measurement Manual Medtronic Sofamor Danek USA, Inc. Adult;Pediatric Supplemental 3.00 2013-07-17 09:26:36.973 Clinical Assessment Physical Examinations Assessments and Examinations

Multiple Pre-Defined Values Selected
C06316 Menstruation scale MenstruationScale Scale for how the female participant's menstruation is affected by the spinal cord injury Scale for how the female participant's menstruation is affected by the spinal cord injur Menstruation Normal;Reduced/altered;Unknown;Not applicable (For female);Not applicable (Patient male) Refers to no change in duration, frequency or quantity of menstrual flow and no change in subjective experience or symptoms of menstruation after the spinal cord lesion;i.e. Menstruation has been initiated, though partially impaired or changed. This refers to a change in the duration, frequency or amount of menstrual blood flow after spinal cord lesion. It can also refer to a change in the quality of sensations or other autonomic phenomena associated with menses;Means the impact of the spinal cord lesion on menstruation is unknown;Means the woman was not menstruating at the time of spinal cord lesion, thus there is not an impact on menstruation; Alphanumeric

Choose one
Normal refers to no change in duration, frequency or quantity of menstrual flow and no change in subjective experience or symptoms of menstruation after the spinal cord lesion.
Reduced/altered, i.e. menstruation has been initiated, though partially impaired or changed. This refers to a change in theduration, frequency or amount of menstrual blood flow after spinal cord lesion. It can also refer to a change in the quality of sensations or other autonomic phenomena associated with menses.
Unknown means the impact of the spinal cord lesion on menstruation is unknown.
Not applicable means the woman was not menstruating at the time of spinal cord lesion, thus there is not an impact on menstruation.

 Alexander MS, Biering-SØrensen F, Elliott S, Kreuter M, SØnksen J. International Spinal Cord Injury Female Sexual and Reproductive Function Basic Data Set. Spinal Cord. 2011 Jul;49(7):787-90. Adult;Pediatric Supplemental 3.00 2013-07-17 09:26:36.973 Clinical Assessment Physical Examinations Assessments and Examinations

Single Pre-Defined Value Selected
C17418 Urine dipstick test leukocyte esterase status UrDipstckTstLeukEstrseStatus Status of leukocyte esterase presence in urine dipstick test which indicates the presence of white blood cells in a urine sample Status of leukocyte esterase presence in urine dipstick test which indicates the presence of white blood cells in a urine sampl Urine dipstick test for leukocyte esterase (tick one only): Negative;Positive;Unknown Negative;Positive;Unknown Alphanumeric

The results can be recorded as negative, positive or unknown. An unknown result could occur from the test being unreadable, unusable, or not done.

 Goetz LL, Cardenas DD, Kennelly M, Bonne Lee BS, Linsenmeyer T, Moser C, Pannek J, Wyndaele JJ, Biering-Sorensen F. International spinal cord injury urinary tract infection basic data set. Spinal Cord. 2013 Sep;51(9):700-4. doi: 10.1038/sc.2013.72. Adult;Pediatric Supplemental 3.00 2013-07-17 09:26:36.973 Clinical Assessment Physical Examinations Assessments and Examinations

Single Pre-Defined Value Selected
C18790 Perianal problem other text PerianlProbOTH The free-text field related to Perianal problem type' specifying other text. Type of problem with the anus found in the perianal space The free-text field related to Perianal problem type' specifying other text. Type of problem with the anus found in the perianal space Other, specify Alphanumeric

For each perianal problem indicate if it was experienced. Perianal problems may change with time and only those present within the last year should be noted.

 Krogh K, Perkash I, Stiens SA, Biering-SØrensen F. International bowel function basic spinal cord injury data set. Spinal Cord. 2009 Mar;47(3):230-4 Adult;Pediatric Supplemental 3.00 2013-07-17 09:26:36.973 Clinical Assessment Physical Examinations Assessments and Examinations 4000

Free-Form Entry
C06220 Fecal incontinence liquid stools frequency FclIncntncLiqStlFreq The frequency of fecal incontinence to liquid stools within the last three months. The frequency of fecal incontinence to liquid stools within the last three months. Frequency of incontinence to liquid stools (within the last three months): Two or more episodes per day;Once daily;Not every day but at least once per week;Not every week but more than once per month;Once per month;Less than once per month;Never;Not applicable;Unknown Two or more episodes per day;Once daily;Not every day but at least once per week;Not every week but more than once per month;Once per month;Less than once per month;Never;Not applicable;Unknown Alphanumeric

Choose one. If the individual has not had liquid stools within the last three months the code "Never" and not the code "Unknown" should be used. In individuals with episodes of fecal incontinence to liquid stools before the last three months without any episodes within in the last three months the code "Never" and not the code "Less than once per month" be should used. The code "Not applicable" is mainly for individuals with stomas.

 Krogh K, Perkash I, Stiens SA, Biering-SØrensen F. International bowel function extended spinal cord injury data set. Spinal Cord. 2009 Mar;47(3):235-41. Adult;Pediatric Supplemental 3.00 2013-07-17 09:26:36.973 Clinical Assessment Physical Examinations Assessments and Examinations

Single Pre-Defined Value Selected
C06407 Thermoregulation other issue past three month result text ThermOthIssPstThreeMoResltTxt Indicator of whether the subject had other types of thermoregulation conditions or events after spinal cord lesion within the last three months Indicator of whether the subject had other types of thermoregulation conditions or events after spinal cord lesion within the last three month Thermoregulation history after spinal cord lesion within the last three months Other, specify Alphanumeric

Choose one. If yes than specify the condition.

 Karlsson AK, Krassioukov A, Alexander MS, Donovan W, Biering-SØrensen F. International spinal cord injury skin and thermoregulation function basic data set. Spinal Cord. 2012 Jul;50(7):512-6. doi: 10.1038/sc.2011.167. Adult;Pediatric Supplemental 3.00 2013-07-17 09:26:36.973 Clinical Assessment Physical Examinations Assessments and Examinations 4000

Free-Form Entry
C05452 Spinal injury anatomic site SpnlInjAntmicSit Anatomic site(s) of the spine injury represented as level(s) of the spinal-injured vertebrae Anatomic site(s) of the spine injury represented as level(s) of the spinal-injured vertebra Spinal column injury level C0;C1;C2;C3;C4;C5;C6;C7;L1;L2;L3;L4;L5;S1;S2;S3;S4-5;T1;T2;T3;T4;T5;T6;T7;T8;T9;T10;T11;T12 C0;C1;C2;C3;C4;C5;C6;C7;L1;L2;L3;L4;L5;S1;S2;S3;S4-5;T1;T2;T3;T4;T5;T6;T7;T8;T9;T10;T11;T12 Alphanumeric

The element may be included if relevant to the study. For additional details like permissible values, see the data dictionary associated with this CRF.
The element may be included if relevant to the study. For additional details like permissible values, see the data dictionary associated with this CRF.
vC00 represents C0 and is the occiput.
The code vX99 should be used only if the level is completely unknown.
In the case of multiple spinal injuries, a separate entry will be completed for each spinal column injury level.

 Dvorak MF, Wing PC, Fehlings MG, Vaccaro AR, Itshayek E, Biering-Sorensen F, Noonan VK. International Spinal Cord Injury Spinal Column Injury Basic Data Set. Spinal Cord. 2012 Nov;50(11):817-821; doi: 10.1038/sc.2012.60. Adult;Pediatric Supplemental 3.00 2013-07-20 10:21:25.65 Clinical Assessment Physical Examinations Assessments and Examinations

Multiple Pre-Defined Values Selected
C06111 Pneumonia episode require hospitalization past year number PnmnaEpsdReqHsptlztnPstYrNum Number of pneumonia episodes requiring hospitalization occurring after the spinal cord lesion and within the last year Number of pneumonia episodes requiring hospitalization occurring after the spinal cord lesion and within the last year Number of episodes requiring hospitalization Numeric Values

Only answer if there is a history of pneumonia after spinal cord lesion and within the last year. If number of episodes is unknown then code 999 (999 = Unknown).

 Biering-SØrensen F, Krassioukov A, Alexander MS, Donovan W, Karlsson AK, Mueller G, Perkash I, William Sheel A, Wecht J, Schilero GJ.International Spinal Cord Injury Pulmonary Function Basic Data Set. Spinal Cord. 2012 Jun; 50(6):418-21. Adult;Pediatric Supplemental 3.00 2013-07-17 09:26:36.973 Clinical Assessment Physical Examinations Assessments and Examinations

Free-Form Entry
C19357 Diagnosis new during hospital stay indicator DiagNewDuringHospStayInd New diagnoses during hospital stay New diagnoses during hospital stay New diagnosis (indicate SNOMED term and code), describe No;Yes;Unknown No;Yes;Unknown Alphanumeric

Choose one

 Adult;Pediatric Supplemental 1.00 2014-06-12 12:38:52.0 Clinical Assessment Physical Examinations Assessments and Examinations

Single Pre-Defined Value Selected
C06240 Bowel dysfunction impact life quality scale BwlDysfnctnImpctLifQualtyScale The self report scale that describes impact on quality of life caused by neurogenic bowel dysfunction. The self report scale that describes impact on quality of life caused by neurogenic bowel dysfunction. Self reported impact on quality of life due to bowel dysfunction Major impact;Some impact;Little impact;No impact;Unknown Major impact;Some impact;Little impact;No impact;Unknown Alphanumeric

Choose one. Self reported impact on quality of life caused by neurogenic bowel dysfunction covers the subject's own assessment of the impact of all aspects of neurogenic bowel dysfunction.

 Krogh K, Perkash I, Stiens SA, Biering-SØrensen F. International bowel function extended spinal cord injury data set. Spinal Cord. 2009 Mar;47(3):235-41. Adult;Pediatric Supplemental 3.00 2013-07-17 09:26:36.973 Clinical Assessment Physical Examinations Assessments and Examinations

Single Pre-Defined Value Selected
C06447 Spasticity spasm indicator SpasctySpsmInd Indicator of the presence of spasticity/spasms Indicator of the presence of spasticity/spasms Presence of spasticity/spasms Yes;No;Unknown Yes;No;Unknown Alphanumeric

The presence of spasticity / spasms in the upper and lower extremities is captured using the modified Ashworth scale (MAS), i.e. greater than 1 on the MAS, or observation of spasms.

 Bohannon RW, Smith MB. Interrater reliability of a Modified Ashworth Scale of muscle spasticity. Physical Therapy. 1987:67:206-7.<br />Biering-S&Oslash;rensen F, Burns AS, Curt A, Harvey LA, Jane Mulcahey M, Nance PW, Sherwood AM, Sisto SA. International spinal cord injury musculoskeletal basic data set. Spinal Cord. 2012 Nov;50(11):797-802; doi: 10.1038/sc.2012.102.<br />Biering-S&Oslash;rensen F, Burns AS, Curt A, Harvey LA, Jane Mulcahey M, Nance PW, Sherwood AM, Sisto SA. International spinal cord injury musculoskeletal basic data set. Spinal Cord. 2012 Nov;50(11):797-802; doi: 10.1038/sc.2012.102. Adult;Pediatric Supplemental 3.00 2013-07-17 09:26:36.973 Clinical Assessment Physical Examinations Assessments and Examinations

Single Pre-Defined Value Selected
C06198 Perianal problem type PerianlProbTyp Type of problem with the anus found in the perianal space Type of problem with the anus found in the perianal space Perianal problems (within the last year): Hemorrhoids;Perianal sores;Fissures;Other, specify;Unknown Hemorrhoids;Perianal sores;Fissures;Other, specify;Unknown Alphanumeric

For each perianal problem indicate if it was experienced. Perianal problems may change with time and only those present within the last year should be noted.
Due to staining and assisted defecation haemorrhoids, fissures, and rectal prolapse are more common among individuals with SCI than in the general population. Anal soiling may contribute to perianal sores. In the present data set perianal sores are located within the crena ani or the perineum and not on the buttocks or lower back. For practical purposes no distinction is made in the present data set between rectal mucosal prolapse and full-wall rectal prolapse.

 Krogh K, Perkash I, Stiens SA, Biering-S&Oslash;rensen F. International bowel function basic spinal cord injury data set. Spinal Cord. 2009 Mar;47(3):230-4 Adult;Pediatric Supplemental 3.00 2013-07-17 09:26:36.973 Clinical Assessment Physical Examinations Assessments and Examinations

Multiple Pre-Defined Values Selected
C21631 Swallowing post-SCI problem indicator SwallowingPostSCIProbInd Subject's response concerning problems with swallowing post-SCI Subject's response concerning problems with swallowing post-SC Since your spinal cord injury, have you had any problems with your swallowing? No;Yes No;Yes Alphanumeric Adult;Pediatric Supplemental 1.00 2014-01-06 00:00:00.0 Clinical Assessment Physical Examinations Assessments and Examinations

Single Pre-Defined Value Selected
C06317 Psychogenic erection scale PsychogenicErectionScale Psychogenic erection is erection that occurs solely based on arousal in the brain e.g. through hearing, seeing, feeling or fantasy (erotic thoughts). Psychogenic erection is penile tumescence with resulting increase in size and firmness of the penis that occurs without physical stimulation, which in usual circumstances should be adequate to allow penetration Psychogenic erection is erection that occurs solely based on arousal in the brain e.g. through hearing, seeing, feeling or fantasy (erotic thoughts). Psychogenic erection is penile tumescence with resulting increase in size and firmness of the penis that occurs without physical stimulation, which in usual circumstances should be adequate to allow penetratio Pyschogenic Erection Absent;Normal;Not applicable (Patient female);Reduced/altered;Unknown Refers to a complete inability to achieve penile tumescence and firmness to psychologic stimulation after the spinal cord lesion;Refers to presence of an ability to achieve and maintain erections in response to psychologic stimulation after spinal cord lesion that is equivalent in quality and duration as prior to spinal cord lesion;;Refers to presence of an ability to achieve erections in response to psychologic stimulation that is partially impaired or altered in quality and/or duration as compared to prior to the spinal cord lesion;Refers to reports by individuals that have not been sexually active after the spinal cord lesion thus they do not know if they have changes in psychogenic erection Alphanumeric

Choose one
In able-bodied men erections are usually a combination of psychogenic and reflex; however, in men with spinal cord lesions, varying types of erectile function may be preserved (Courtois, 1993, 1995; Giuliano 1995).
Psychogenic erection potential may be based on degree of preservation of sensory function in T11-L2 dermatomes.

 Alexander MS, Biering-S&Oslash;rensen F, Elliott S, Kreuter M, S&Oslash;nksen J. International Spinal Cord Injury Male Sexual Function Basic Data Set. Spinal Cord. 2011 Jul;49(7):795-8. Courtois FJ, Charvier KF, Leriche A, Raymond DP. Sexual function in spinal cord injured men. I. Assessing sexual capacity. Paraplegia. 1993;31:771-784. Courtois FJ, Charvier KF, Leriche A, Raymond DP, Eyssette M. Clinical approach to erectile dysfunction in spinal cord injured men. A review of clinical and experimental data. Paraplegia. 1995;33;628-635. Giuliano FA, Rampin O, Benoit G Jardin A. Neural control of penile erection. Uro Clin North Am. 1995;22(4):747-66. Adult;Pediatric Supplemental 3.00 2013-07-17 09:26:36.973 Clinical Assessment Physical Examinations Assessments and Examinations

Single Pre-Defined Value Selected
C17419 Urinary culture status UrCultStatus Status of urine culture result Status of urine culture result Urine culture (tick one only): Negative;Positive;Unknown Negative;Positive;Unknown Alphanumeric

The results can be recorded as negative, positive or unknown. An unknown result could occur from the test being unreadable, unusable, or not done.

 Goetz LL, Cardenas DD, Kennelly M, Bonne Lee BS, Linsenmeyer T, Moser C, Pannek J, Wyndaele JJ, Biering-Sorensen F. International spinal cord injury urinary tract infection basic data set. Spinal Cord. 2013 Sep;51(9):700-4. doi: 10.1038/sc.2013.72. Adult;Pediatric Supplemental 3.00 2013-07-17 09:26:36.973 Clinical Assessment Physical Examinations Assessments and Examinations

Single Pre-Defined Value Selected
C18791 Bowel care position past three months other text BowelCrPostnPstThrMoOTH The free-text field related to 'Bowel care position past three months type' specifying other text. The indicator of whether the bowel care position was used within the past three months The free-text field related to 'Bowel care position past three months type' specifying other text. The indicator of whether the bowel care position was used within the past three month Other, specify Alphanumeric

For each bowel care position indicate if it was used within the last three months

 Krogh K, Perkash I, Stiens SA, Biering-S&Oslash;rensen F. International bowel function extended spinal cord injury data set. Spinal Cord. 2009 Mar;47(3):235-41. Adult;Pediatric Supplemental 3.00 2013-07-17 09:26:36.973 Clinical Assessment Physical Examinations Assessments and Examinations 4000

Free-Form Entry
C06221 Fecal incontinence solid stools frequency FclIncntncSldStlFreq The frequency of fecal incontinence to solid stools within the last three months. The frequency of fecal incontinence to solid stools within the last three months. Frequency of incontinence to solid stools (within the last three months): Two or more episodes per day;Once daily;Not every day but at least once per week;Not every week but more than once per month;Once per month;Less than once per month;Never;Not applicable;Unknown Two or more episodes per day;Once daily;Not every day but at least once per week;Not every week but more than once per month;Once per month;Less than once per month;Never;Not applicable;Unknown Alphanumeric

In individuals with episodes of fecal incontinence to solid stools before the last three months without any episodes within the last three months the code "Never" and not the code "Less than once per month" should used. The code "Not applicable" is mainly for individuals with stomas.

 Krogh K, Perkash I, Stiens SA, Biering-S&Oslash;rensen F. International bowel function extended spinal cord injury data set. Spinal Cord. 2009 Mar;47(3):235-41. Adult;Pediatric Supplemental 3.00 2013-07-17 09:26:36.973 Clinical Assessment Physical Examinations Assessments and Examinations

Single Pre-Defined Value Selected
C06408 Skin thermoregulation pressure ulcer present indicator SkiThermPressrUlcPrstInd Indicator of the presence of a pressure ulcer at the time of investigation Indicator of the presence of a pressure ulcer at the time of investigatio Any pressure ulcer at present Yes;No;Unknown Yes. If yes. Fill in one diaram for each ulce by indicating the ulcerstage (I II III IV U (nstageable)) at the appropriate location;No;Unknown Alphanumeric

Choose one
A pressure ulcer could be present at any time post spinal cord injury. This variable documents the presence of pressure ulcer(s) at the time of investigation. An ulcer is usually seen on prominent body structures and caused by pressure on the region. The location of the pressure ulcer should be documented including right/left side of the body when applicable.

 Karlsson AK, Krassioukov A, Alexander MS, Donovan W, Biering-S&Oslash;rensen F. International spinal cord injury skin and thermoregulation function basic data set. Spinal Cord. 2012 Jul;50(7):512-6. doi: 10.1038/sc.2011.167. Adult;Pediatric Supplemental 3.00 2013-07-17 09:26:36.973 Clinical Assessment Physical Examinations Assessments and Examinations

Single Pre-Defined Value Selected
C06005 Data collected date and time DataCollDateTime Date (and time, if applicable and known) the data were collected. This may be the date/time a particular examination or procedure was performed Date (and time, if applicable and known) the data were collected. This may be the date/time a particular examination or procedure was performe Assessment Date/Time 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.).
Injury through the spinal column is defined as any break, rupture, ligament tear, disruption, or crack through the bony vertebral elements or through the non-bony disc and ligamentous soft tissues between the vertebrae from the occipital condyles to the sacrum. Patients with cervical spondylosis and spinal stenosis may suffer a traumatic spinal cord injury without a spinal column injury.

 Dvorak MF, Wing PC, Fehlings MG, Vaccaro AR, Itshayek E, Biering-Sorensen F, Noonan VK. International spinal cord injury spinal column injury basic data set. Spinal Cord. 2012 Nov;50(11):817-21. Adult;Pediatric Supplemental 3.00 2013-07-24 21:00:23.88 Clinical Assessment Physical Examinations Assessments and Examinations

Free-Form Entry
CSV