CDE Detailed Report
Subdomain Name: Physical Examinations
CRF: Clinical Assessment
Displaying 1 - 50 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 |
---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
C19091 | Urinary tract surgical procedure indicator | UrinaryTractSurgProcedInd | Indicator for surgical procedure on the urinary tract | Indicator for surgical procedure on the urinary tract | Surgical procedures on the urinary tract: | No;Yes;Unknown | No;Yes;Unknown | Alphanumeric |
Bladder stone or upper urinary tract stone removal includes any type of removal, including via endoscopy, extracorporal shock wave lithotripsy (ESWL), or open lithotomy. |
Biering-SØrensen F, Craggs M, Kennelly M, Schick E, Wyndaele JJ. International Lower Urinary Tract Function Basic Spinal Cord Injury Data Set. Spinal Cord 2008 May;46(5):325-30. | Adult;Pediatric | Supplemental | 1.00 | 2014-05-27 15:00:45.0 | Clinical Assessment | Physical Examinations | Assessments and Examinations |
Single Pre-Defined Value Selected |
||||||||
C06237 | Bowel care time stool pass care past three months average duration | BwlCrTmStlPssCrPstThrMoAvgDur | The average time duration spent waiting after last stool passes before ending bowel care within the last three months. | The average time duration spent waiting after last stool passes before ending bowel care within the last three months. | Events and intervals of defecation (3): Average time spent waiting after last stool passes before ending bowel care (within the last three months): | Numeric Values |
Record in time duration in minutes based on each individual's own assessment of time consumption. This element begins at the end of the previous element (Stool intermittent or continuous defecation with or without assistance past three months average duration). |
House JG, Stiens SA. Pharmacologically initiated defecation for persons with spinal cord injury: effectiveness of three agents. Arch Phys Med Rehabil 1997; 78: 1062-1065. 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 |
Free-Form Entry |
minute | |||||||||
C06435 | Neuro-Musculoskeletal condition type | NeuroMuscskltlCondTyp | Type of neuro-musculoskeletal condition experienced or diagnosed | Type of neuro-musculoskeletal condition experienced or diagnosed | Fractures, heterotopic ossifications, contractures, or degenerative changes/overuse | Fracture;Heterotopic ossification;Contracture;Degenerative change/overuse | Fracture;Heterotopic ossification;Contracture;Degenerative change/overuse | Alphanumeric |
Identifies whether the anatomic site and laterality type describes the fracture, heterotopic ossification, contracture, or degenerative change/overuse |
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 |
Single Pre-Defined Value Selected |
||||||||
C06054 | Urinary symptom change past year indicator | UrinSympChngPstYrInd | Indicator of whether there were any change in urinary symptoms within the last year | Indicator of whether there were any change in urinary symptoms within the last year | Any change in urinary symptoms within the last year | No;Yes;Not applicable;Unknown | No;Yes;Not applicable;Unknown | Alphanumeric |
Lower urinary tract symptoms are according to the International Continence Society the subjective indicator of a disease or change in conditions as perceived by the individual with spinal cord lesion, attendant or partner and may lead him/her to seek help from health care professionals (Abrams et al. 2002). Symptoms may either be volunteered or described during the data collection interview with the individual with spinal cord lesion. The information may be qualitative as well as quantitative, e.g. change in frequency, urgency, nocturia, incontinence, hesitancy, slow stream, etc. "Not applicable" is to be used when data reporting is performed within the first year after the spinal cord lesion. |
Abrams P, Cardozo L, Fall M, Griffiths D, Rosier P, Ulmsten U, van Kerrebroeck P, Victor A, Wein A. The Standardization of Terminology of Lower Urinary Tract Function: Report from the Standardization Sub-committee of the International Continence Society. Biering-SØrensen F, Craggs M, Kennelly M, Schick E, Wyndaele JJ. International Lower Urinary Tract Function Basic Spinal Cord Injury Data Set. Spinal Cord 2008 May;46(5):325-30. | Adult;Pediatric | Supplemental | 3.00 | 2013-07-17 09:26:36.973 | Clinical Assessment | Physical Examinations | Assessments and Examinations |
Single Pre-Defined Value Selected |
||||||||
C06193 | Diaper pad plug use past four week indicator | DiapPadPlugPstFourWkInd | Indicator for need to wear a diaper, pad or plug within the last four weeks | Indicator for need to wear a diaper, pad or plug within the last four weeks | Need to wear diaper, pad or plug | No;Yes;Unknown | No;Yes;Unknown | Alphanumeric |
Within the last four weeks, choose one. The need to wear a pad only for urinary incontinence should not be included. |
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 |
||||||||
C21618 | Bowel care time stool pass care past three month average indicator | BwlCrTmStlPsCrPstThrMoAvgInd | The indicator related to average time duration spent waiting after last stool passes before ending bowel care within the last three months | The indicator related to average time duration spent waiting after last stool passes before ending bowel care within the last three month | Events and intervals of defecation (3): Average time spent waiting after last stool passes before ending bowel care (within the last three months): | Not applicable;Unknown | Not applicable;Unknown | Alphanumeric |
Record in time duration in minutes based on each individual's own assessment of time consumption. This element begins at the end of the previous element (Stool intermittent or continuous defecation with or without assistance past three months average duration). |
House JG, Stiens SA. Pharmacologically initiated defecation for persons with spinal cord injury: effectiveness of three agents. Arch Phys Med Rehabil 1997; 78: 1062-1065. 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 |
||||||||
C06314 | Reflex genital arousal scale | ReflexGenitalArousalScale | Scale for how the female's reflex genital arousal is affected by the spinal cord injury | Scale for how the female's reflex genital arousal is affected by the spinal cord injur | Relfex Genital Arousal | Normal;Reduced/altered;Absent;Unknown;Not applicable (Patient male) | No change in time to achieve lubrication, amount of lubrication or duration of lubrication with genital stimulation subsequent to the spinal cord lesion;Includes reports of either altered time (longer or shorter) to achieve, amount of lubrication, or duration of lubrication. It would also include reports of excessive reflex lubrication. Absent refers to individuals having no awareness of lubrication despite being genitally stimulated;Reflex arousal is thought to only to happen in the presence of complete cauda equina or conus lesion;Refers to reports by individuals that they have not been sexually active thus they do not know if they are able to achieve reflex arousal after the spinal cord lesion; | Alphanumeric |
Choose one. When querying individuals about reflex arousal it is recommended that the interviewer focus on the woman's awareness of vaginal lubrication as opposed to clitoral engorgement. |
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 |
||||||||
C17416 | Urinary tract infection symptom other text | UTISymptmOthrTxt | Text field to specify a symptom (other than those pre-defined) associated with a bacterial infectious process affecting any part of the urinary tract, most commonly the bladder and the urethra | Text field to specify a symptom (other than those pre-defined) associated with a bacterial infectious process affecting any part of the urinary tract, most commonly the bladder and the urethr | Other, specify | Alphanumeric | 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 | 255 |
Free-Form Entry |
||||||||||
C18786 | Defecation method bowel care procedure used past four week main other text | DefctnMthdBwlProcedUseMainOTH | The free-text field related to 'Defecation method bowel care procedure used past four week main type' specifying other text. Type of main defecation method and bowel care procedures used within the last four weeks | The free-text field related to 'Defecation method bowel care procedure used past four week main type' specifying other text. Type of main defecation method and bowel care procedures used within the last four week | Other, specify | Alphanumeric | 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 |
||||||||||
C06218 | Perianal pain defecation frequency | PernlPainDefctnFreq | The frequency of any perianal pain during defecation within the last three months | The frequency of any perianal pain during defecation within the last three month | Perianal pain during defecation (within the last three months): | Daily;Not every day but at least once per week;Not every week but at least once per month;Less than once per month;Never;Not applicable;Unknown | Daily;Not every day but at least once per week;Not every week but at least once per month;Less than once per month;Never;Not applicable;Unknown | Alphanumeric |
Choose one. Most individuals with complete SCI are unable to feel perianal pain during defecation. In such cases the code "Never" and not the code "Unknown" should be used. Indirect indicators of perianal pain during defecation such as perspiration, spasms or headache are not registered here. 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 |
||||||||
C06405 | Hyperhidrosis past three months status | HyprhdrPstThreeMoStatus | Status of whether the subject had hyperhidrosis after spinal cord lesion within the last three months. Hyperhidrosis is defined as excessive sweating above or below level of injury in the absence of increased ambient temperature | Status of whether the subject had hyperhidrosis after spinal cord lesion within the last three months. Hyperhidrosis is defined as excessive sweating above or below level of injury in the absence of increased ambient temperatur | Thermoregulation history after spinal cord lesion within the last three months Hyperhidrosis | 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 |
||||||||
C00313 | Medical history condition SNOMED CT code | MedclHistCondSNOMEDCTCode | Systematized Nomenclature Of Medicine Clinical Terms (SNOMED CT) code for medical condition/disease reported by the participant/subject | Systematized Nomenclature Of Medicine Clinical Terms (SNOMED CT) code for medical condition/disease reported by the participant/subject | If YES, new diagnosis (indicate SNOMED term and code), describe | Alphanumeric |
Code each of the new diagnoses made using SNOMED CT. |
Adult;Pediatric | Supplemental | 3.00 | 2013-07-25 08:54:08.2 | Clinical Assessment | Physical Examinations | Assessments and Examinations | 255 |
Free-Form Entry |
||||||||||
C19092 | Urinary tract surgical procedure other text | UrinaryTractSurgProcedOTH | The free text field related to "Urinary tract surgical procedures indicator" specifying the other text. The type of procedure | The free text field related to "Urinary tract surgical procedures indicator" specifying the other text. The type of procedur | other, specify | Alphanumeric | Biering-SØrensen F, Craggs M, Kennelly M, Schick E, Wyndaele JJ. International Lower Urinary Tract Function Basic Spinal Cord Injury Data Set. Spinal Cord 2008 May;46(5):325-30 | Adult;Pediatric | Supplemental | 1.00 | 2014-05-27 15:15:49.0 | Clinical Assessment | Physical Examinations | Assessments and Examinations | 4000 |
Free-Form Entry |
||||||||||
C06238 | Anal incontinence lifestyle alteration past three months scale | AnlInctncLifstylAltPstThrMoScl | The scale that assesses lifestyle alteration due to anal incontinence within the last three months. | The scale that assesses lifestyle alteration due to anal incontinence within the last three months. | Lifestyle alteration due to anal incontinence (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 to anal incontinence or the risk of anal incontinence. Examples may by avoidance of social activities, traveling, sexual activities etc. 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 |
||||||||
C06436 | Neuro-Musculoskeletal condition anatomic site | NeuroMuscskltlCondAntmicSite | Anatomic site of the neuro-musculoskeletal condition experienced or diagnosed | Anatomic site of the neuro-musculoskeletal condition experienced or diagnosed | Location | Neck/Cervical spine;Shoulder/Humerus;Elbow;Forearm;Wrist;Hand;Upper back/Thoracic spine;Lower back/Lumbar spine;Pelvis;Hip/Femur;Knee;Tibia/Fibula;Ankle;Foot | Neck/Cervical spine;Shoulder/Humerus;Elbow;Forearm;Wrist;Hand;Upper back/Thoracic spine;Lower back/Lumbar spine;Pelvis;Hip/Femur;Knee;Tibia/Fibula;Ankle;Foot | Alphanumeric |
Choose one for each neuro-musculoskeletal condition (fracture, heterotopic ossification, contracture, or degenerative change/overuse) |
Fergusson D, Hutton B and Drodge A. The epidemiology of major joint contractures: A systematic review of the literature. Clinical Orthopaedics and Related Research. 2006;14:22-29. Apple, D, Cody, R, Allen, A. Overuse Syndrome of the Upper Limb in People With Spinal Cord Injury. In: Apple, DF, Editor, Physical Fitness: A guide for individuals with spinal cord injury. Journal of Rehabilitation Research and Development, Chapter 5, 1996 (Clinical Supplement): 97-108<br />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 |
Single Pre-Defined Value Selected |
||||||||
C06109 | Pulmonary condition after spinal cord lesion last year type | PulmnCndAftrSpnlCrdLsnLstYrTyp | Type of pulmonary complication or condition that may have occurred after the spinal cord lesion (within the last year) | Type of pulmonary complication or condition that may have occurred after the spinal cord lesion (within the last year) | Pulmonary complications and conditions after the spinal cord lesion within last year | Pneumonia;Chronic obstructive pulmonary disease;Sleep apnea;Other, specify;Unknown;None | Pneumonia;Chronic obstructive pulmonary disease (including emphysema and chronic bronchitis);Sleep apnea;Other, specify;Unknown;None | Alphanumeric |
For each pulmonary complication or condition indicate if occurred within the last year. |
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 |
Multiple Pre-Defined Values Selected |
||||||||
C06194 | Bowel function medication constipating agent type | BwlFUncMedConstAgtTyp | Type of medication affecting bowel function / constipating agents | Type of medication affecting bowel function / constipating agents | If yes, specify medication affecting bowel function/constipating agents | Anticholinergics;Narcotics;Other,specify | Anticholinergics;Narcotics;Other, specify | Alphanumeric |
For each medication type indicate if it was used. This element does not only include orally taken agents, patches, suppositories, injections, or laxatives. |
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 |
Multiple Pre-Defined Values Selected |
||||||||
C21629 | Hip instability indicator | HipInstabilityInd | Indicator related to whether the participant/subject has any hip instability, subluxation or pelvic obiquity | Indicator related to whether the participant/subject has any hip instability, subluxation or pelvic obiquity | Hip instability, subluxation and pelvic obiquity | No;Yes | No;Yes | Alphanumeric |
Choose one |
Adult;Pediatric | Supplemental | 3.00 | 2013-07-17 09:26:36.973 | Clinical Assessment | Physical Examinations | Assessments and Examinations |
Single Pre-Defined Value Selected |
|||||||||
C06315 | Orgasmic function scale | OrgasmicFunctScale | Scale that assesses orgasmic function. Females: Orgasm is the perception of sensation of feeling good through sexual stimulation, of reaching a climax after which the woman feels gratified. May be accompanied by an overall increase and then decrease in muscle tone. The potential is based on history. Males: Orgasm is the perception of sensation of a peak feeling of sexual release, or climax, after which the man feels gratified. It may be accompanied by an overall increase and then decrease in muscle tone and may or may not be accompanied by ejaculation. The potential is based on history | Psychogenic genital arousal usually manifests itself as the presence of clitoral engorgement and vaginal lubrication, amongst other signs, and occurs from arousal generated from the brain e.g. through hearing, seeing, feeling or fantasy (erotic thoughts) | Orgasmic Function | Normal;Reduced/altered;Absent;Unknown | Normal;Reduced/altered;Absent;Unknown | Alphanumeric |
Choose one |
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 |
||||||||
C17417 | Urine dipstick test nitrite status | UrDipstckTstNitrStatus | Status of nitrite presence in urine dipstick test | Status of nitrite presence in urine dipstick test | Urine dipstick test for nitrite (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 |
||||||||
C18787 | Defecation method bowel care procedure used past four week supplementary other text | DefctnMthdBwlProcedUseSuppOTH | The free-text field related to 'Defecation method bowel care procedure used past four week supplementary type' specifying other text. Type or types of supplemental defecation methods and bowel care procedures used within the last four weeks. Supplementary methods should be performed at least once every week | The free-text field related to 'Defecation method bowel care procedure used past four week supplementary type' specifying other text. Type or types of supplemental defecation methods and bowel care procedures used within the last four weeks. Supplementary methods should be performed at least once every wee | Other, specify | Alphanumeric | 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 |
||||||||||
C06219 | Flatus incontinence frequency | FltsIncntncFreq | The frequency of flatus incontinence within the last three months. | The frequency of flatus incontinence within the last three months. | Frequency of flatus incontinence (within the last three months): | Daily;Not every day but at least once per week;Not every week but at least once per month;Less than once per month;Never;Not applicable;Unknown | Daily;Not every day but at least once per week;Not every week but at least once per month;Less than once per month;Never;Not applicable;Unknown | Alphanumeric |
Choose one. 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 |
||||||||
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 |
||||||||||
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 |
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 |
||||||||||
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 |
||||||||||
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 |
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. |
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 |
||||||||
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-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.<br />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 |
Single Pre-Defined Value 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 |
||||||||||
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. |
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 |
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 |
Alexander MS, Biering-SØrensen F, Elliott S, Kreuter M, SØnksen 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-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 | 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-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 |
||||||||
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 |
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 |
||||||||
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.). |
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 |
||||||||||
C06112 | Ventilatory assistance type | VentiltryAsstTyp | Type of assistance device utilized to augment ventilation | Type of assistance device utilized to augment ventilation | Current Utilization of Ventilatory Assistance | Bi-level Positive Airway Pressure;Diaphragmatic pacing device;Mechanical ventilation;None;Other,specify;Phrenic Nerve Stimulation;Unknown | Bi-level Positive Airway Pressure (BiPAP);Diaphragmatic pacing device;Mechanical ventilation;None;Other, specify;Phrenic Nerve Stimulation;Unknown | Alphanumeric |
Record any assistance device utilized at the time of evaluation to augment ventilation. For each device indicate if it was utilized at the time of evaluation. |
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 |
Multiple Pre-Defined Values Selected |
||||||||
C19467 | Bladder empty method main other text | BladEmpMethdMainOTH | The free-text field to specify the main method of bladder emptying | The free-text field to specify the main method of bladder emptyin | Other method, specify | Alphanumeric | Abrams P, Cardozo L, Fall M, Griffiths D, Rosier P, Ulmsten U, van Kerrebroeck P, Victor A, Wein A. The Standardisation of Terminology of Lower Urinary Tract Function: Report from the Standardisation Sub-committee of the International Continence Society. Neurourology and Urodynamics 2002:21;167-78. Biering-SØrensen F, Craggs M, Kennelly M, Schick E, Wyndaele JJ. International Lower Urinary Tract Function Basic Spinal Cord Injury Data Set. Spinal Cord 2008 May;46(5):325-30. Levi R, Ertzgaard P, The Swedish Spinal Cord Injury Council 1998. Quality indicators in spinal cord injury care: A Swedish collaboration project. Scand J Rehabil Med 1998;Suppl.38:1-80. | Adult;Pediatric | Supplemental | 3.00 | 2013-07-17 09:26:36.973 | Clinical Assessment | Physical Examinations | Assessments and Examinations | 4000 |
Free-Form Entry |