CDE Detailed Report
Subdomain Name: Vital Signs and Other Body Measures
CRF: Vital Signs and Tests
Displaying 1 - 50 of 55
| 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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| C06260 | Bladder function bladder compliance type | BldrFuncBladderComplianceTyp | Type of bladder compliance of the participant/subject during filling cystometry | Type of bladder compliance of the participant/subject during filling cystometry | Compliance during filing cystometry: Low (< 10 mL/cm H20) | Yes;No;Unknown | Yes;No;Unknown | Alphanumeric |
The International Continence Society recommends to calculate the bladder compliance using two standard points: 1) the detrusor pressure at the start on the bladder filling and the corresponding bladder volume (usually zero), and 2) the detrusor pressure (and corresponding bladder volume) at cystometric capacity or immediately before the start of any detrusor contraction that causes significant leakage (and therefore causes the bladder volume to decrease, affecting compliance calculation). Both points are measured excluding any detrusor contraction (Abrams et al. 2002). Unknown is used if the observation regarding bladder compliance during filling cystometry is not available. |
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 urodynamic basic spinal cord injury data set. Spinal Cord 2008 Jul;46(7):513-6. Weld KJ, Graney MJ, Dmochowski RR. Differences in bladder compliance with time and associations of bladder management with compliance in spinal cord injured patients. J Urol 2000;163:1228-33. | Adult | Supplemental | 3.00 | 2013-07-17 09:26:36.973 | Vital Signs and Tests | Vital Signs and Other Body Measures | Assessments and Examinations |
Single Pre-Defined Value Selected |
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| C18133 | Cystogram performed date | CystogramDate | Date Cystogram was performed | Date Cystogram was performed | Date performed: | 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, Craggs M, Kennelly M, Schick E, Wyndaele J-J. International urinary tract imaging basic spinal cord injury data set. Spinal Cord 2009;47:379-83. | Adult | Supplemental | 3.00 | 2013-07-17 09:26:36.973 | Vital Signs and Tests | Vital Signs and Other Body Measures | Assessments and Examinations |
Free-Form Entry |
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| C06115 | Force vital capacity measurement | FrceVitalCpctyMeasr | Forced vital capacity (FVC) value measured in liters using simple spirometry. FVC is defined as the total volume of air that a person can forcibly exhale during a maximal expiratory effort | Forced vital capacity (FVC) value measured in liters using simple spirometry. FVC is defined as the total volume of air that a person can forcibly exhale during a maximal expiratory effor | Forced vital capacity (FVC) | Numeric Values |
Forced vital capacity (FVC) should be reported in liters (99.9 = 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 | Supplemental | 3.00 | 2013-07-17 09:26:36.973 | Vital Signs and Tests | Vital Signs and Other Body Measures | Assessments and Examinations |
Free-Form Entry |
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| C19340 | Mean arterial pressure measurement value | MeanArtPressrMeasrVal | Result of a mean average pressure determination, expressed as a numeric value in millimeters of mercury (mmHg) to the nearest even number. The average pressure on the arteries from the beginning of one heartbeat to the beginning of the next heartbeat. Formally, it is the product of the cardiac output and the systemic vascular resistance, plus the central venous pressure | Result of a mean average pressure determination, expressed as a numeric value in millimeters of mercury (mmHg) to the nearest even number. The average pressure on the arteries from the beginning of one heartbeat to the beginning of the next heartbeat. Formally, it is the product of the cardiac output and the systemic vascular resistance, plus the central venous pressur | Mean arterial pressure measurement (mmHg) | Numeric Values | Adult;Pediatric | Supplemental | 1.00 | 2014-06-11 10:20:24.0 | Vital Signs and Tests | Vital Signs and Other Body Measures | Assessments and Examinations |
Free-Form Entry |
millimeters of mercury | 2475893 | ||||||||||
| C06156 | Kidney stone laterality type | KdnyStnInd | The laterality type related to kidney stones present. This means urinary stone(s) was/were found in the renal pelvis or renal parenchyma on either side | The laterality type related to kidney stones present. This means urinary stone(s) was/were found in the renal pelvis or renal parenchyma on either sid | Kidney stone | Right side;Left side | Right side;Left side | Alphanumeric |
Choose one |
Biering-SØrensen F, Craggs M, Kennelly M, Schick E, Wyndaele J-J. International urinary tract imaging basic spinal cord injury data set. Spinal Cord 2009;47:379-83. | Adult | Supplemental | 3.00 | 2013-07-17 09:26:36.973 | Vital Signs and Tests | Vital Signs and Other Body Measures | Assessments and Examinations |
Single Pre-Defined Value Selected |
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| C06261 | Bladder function urethral function type | BldrFuncUrethralFuncTyp | Type of urethral function of the participant/subject during voiding | Type of urethral function of the participant/subject during voiding | Urethral function during voiding | Normal;Detrusor sphincter dyssynergia;Non-relaxing urethral sphincter obstruction;Not applicable;Unknown | Is defined as a urethra that opens and is continuous relaxed to allow the bladder to be emptied at a normal pressure (Abrams et al. 2002).;Is defined as detrusor contraction concurrent with an involuntary contraction of the urethral and/or periurethral striated muscle. Occasionally flow may be prevented altogether (Abrams et al. 2002).;Is characterised by a non-relaxing, obstructing urethra resulting in reduced urine flow (Abrams et al. 2002).;Should be used if the individual with a spinal cord lesion for example has acontractile detrusor.;Is used if the observation regarding function during voiding is not available. | Alphanumeric |
Choose one |
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 urodynamic basic spinal cord injury data set. Spinal Cord 2008 Jul;46(7):513-6. | Adult | Supplemental | 3.00 | 2013-07-17 09:26:36.973 | Vital Signs and Tests | Vital Signs and Other Body Measures | Assessments and Examinations |
Single Pre-Defined Value Selected |
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| C18134 | Cystogram result type | CystogramResTyp | The type as related to the cystrogram result | The type as related to the cystrogram result | Cystogram | Bladder stone;Vesicoureteric reflux;Normal;Other findings;Bladder diverticulum;Bladder neck at rest | Bladder stone;Vesicoureteric reflux;Normal;Other findings;Bladder diverticulum;Bladder neck at rest | Alphanumeric |
Normal: Normal anatomical conditions werefound at the investigation; in particular, no stones in the bladder,vesicoureteral reflux, or bladder diverticulum. |
Biering-SØrensen F, Craggs M, Kennelly M, Schick E, Wyndaele J-J. International urinary tract imaging basic spinal cord injury data set. Spinal Cord 2009;47:379-83. | Adult | Supplemental | 3.00 | 2013-07-17 09:26:36.973 | Vital Signs and Tests | Vital Signs and Other Body Measures | Assessments and Examinations |
Single Pre-Defined Value Selected |
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| C06116 | Force expiratory volume measurement | FrceExpirtryVolMeasr | Forced expiratory volume in one second (FEV1) value measured in liters using simple spirometry. FEV1 is the volume expired in the first second of the forced vital capacity (FVC) maneuver | Forced expiratory volume in one second (FEV1) value measured in liters using simple spirometry. FEV1 is the volume expired in the first second of the forced vital capacity (FVC) maneuve | Forced expiratory volume in one second (FEV1) | Numeric Values |
FEV1 should be reported in liters (99.9 = 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 | Supplemental | 3.00 | 2013-07-17 09:26:36.973 | Vital Signs and Tests | Vital Signs and Other Body Measures | Assessments and Examinations |
Free-Form Entry |
liter | |||||||||
| C19341 | Laboratory procedure creatinine clearance result value | LabProcCreatClearRsltVal | Quantitative results of the laboratory test for creatinine clearance in mL/(min * 1.73 m?) | Quantitative results of the laboratory test for creatinine clearance in mL/(min * 1.73 m?) | Clearance | Numeric Values |
This is an investigation performed with a radioactive isotope marked substance. The value is corrected for the individual's body surface area (1.73 m2). Reference intervals are adjusted for the person's age and the method utilized. |
Biering-SØrensen F, Craggs M, Kennelly M, Schick E, Wyndaele J-J. International urinary tract imaging basic spinal cord injury data set. Spinal Cord 2009;47:379-83. | Adult | Supplemental | 3.00 | 2013-06-11 00:00:00.0 | Vital Signs and Tests | Vital Signs and Other Body Measures | Assessments and Examinations |
Free-Form Entry |
milliliters per (minutes multiplied by 1.73 meters squared) | |||||||||
| C06158 | Ureter stone laterality type | UrtrStnInd | The laterality type related to stone present in the ureter. This means urinary stone(s) was/were found in the ureter on either side | The laterality type related to stone present in the ureter. This means urinary stone(s) was/were found in the ureter on either sid | Stone in ureter | Right side;Left side | Right side;Left side | Alphanumeric |
Choose one |
Biering-SØrensen F, Craggs M, Kennelly M, Schick E, Wyndaele J-J. International urinary tract imaging basic spinal cord injury data set. Spinal Cord 2009;47:379-83. | Adult | Supplemental | 3.00 | 2013-07-17 09:26:36.973 | Vital Signs and Tests | Vital Signs and Other Body Measures | Assessments and Examinations |
Single Pre-Defined Value Selected |
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| C06262 | Bladder function detrusor leak point pressure value | BldrFuncDtrsrLekPntPressrVal | Value of the lowest detrusor pressure on the participant/subject at which urine leakage occurs | The lowest detrusor pressure on the participant/subject at which urine leakage occurs | Detrusor leak point pressure | Numeric Values |
Document the detrusor leak point pressure in cm H2O during filling cystometry. Up to three digits without decimals should be used. |
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 urodynamic basic spinal cord injury data set. Spinal Cord 2008 Jul;46(7):513-6. | Adult | Supplemental | 3.00 | 2013-07-17 09:26:36.973 | Vital Signs and Tests | Vital Signs and Other Body Measures | Assessments and Examinations |
Free-Form Entry |
centimeter of water | |||||||||
| C01507 | Blood pressure diastolic measurement | BldPressrDiastlMeasr | Measurement of pressure of the participant's blood against the artery walls during diastole (the relaxation phase) in millimeters of mercury (mmHg) | Measurement of pressure of the participant's blood against the artery walls during diastole (the relaxation phase) in millimeters of mercury (mmHg) | Blood Pressure | Numeric Values |
Record the diastolic blood pressure of the participant/ subject. The standard unit for measuring blood pressure is mmHg, which is approximately equivalent to Torr. |
Krassioukov A, Alexander MS, Karlsson AK, Donovan W, Mathias CJ, Biering-SØrensen F. International spinal cord injury cardiovascular function basic data set. Spinal Cord. 2010 Aug;48(8):586-90. | Adult;Pediatric | Supplemental | 3.10 | 2024-03-11 10:40:54.0 | Vital Signs and Tests | Vital Signs and Other Body Measures | Assessments and Examinations |
Free-Form Entry |
0 | 300 | millimeter of mercury | 2004291 | ||||||
| C18136 | Void cystogram results type | VoidCystogramResTyp | Results of voiding cystogram performed on the urinary tract | Results of voiding cystogram performed on the urinary tract | Voiding cystogram / Micturition cystourogram (MCU) / Videourodynamic | Bladder neck during voiding;Normal;Striated urethral sphincter during voiding;Vesicoureteric reflux | Bladder neck during voiding;Normal;Striated urethral sphincter during voiding;Vesicoureteric reflux | Alphanumeric | Biering-SØrensen F, Craggs M, Kennelly M, Schick E, Wyndaele J-J. International urinary tract imaging basic spinal cord injury data set. Spinal Cord 2009;47:379-83. | Adult | Supplemental | 3.00 | 2013-07-17 09:26:36.973 | Vital Signs and Tests | Vital Signs and Other Body Measures | Assessments and Examinations |
Single Pre-Defined Value Selected |
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| C06117 | Peak expiratory flow measurement | PkExpirtryFlowMeasr | Peak expiratory flow (PEF) value measured in liters/minute. PEF is the maximal expiratory flow rate achieved during the forced vital capacity (FVC) maneuver | Peak expiratory flow (PEF) value measured in liters/minute. PEF is the maximal expiratory flow rate achieved during the forced vital capacity (FVC) maneuve | Peak expiratory flow (PEF) | Numeric Values |
PEF should be reported in liters/minute (99.9 = 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 | Supplemental | 3.00 | 2013-07-17 09:26:36.973 | Vital Signs and Tests | Vital Signs and Other Body Measures | Assessments and Examinations |
Free-Form Entry |
liters per minute | |||||||||
| C19342 | Measurement not reported reason | MeasrmntNotReptdRsn | The reason that a value was not reported for a measurement | The reason that a value was not reported for a measuremen | Mark if "Not applicable" or "Unknown" | Not applicable;Unknown | Not applicable;Unknown | Alphanumeric | Adult | Supplemental | 1.00 | 2014-06-11 13:48:56.0 | Vital Signs and Tests | Vital Signs and Other Body Measures | Assessments and Examinations |
Single Pre-Defined Value Selected |
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| C06161 | Bladder neck during voiding status | BldrNckDurVoidStatus | Status of the bladder neck during voiding | Status of the bladder neck during voiding | Bladder neck during voiding | Normal;Closed | Normal bladder neck function is when the bladder neck opens, and is continuously relaxed to allow the bladder to be emptied at normal pressure.;Closed bladder neck during voiding (dyssynergia) is when the detrusor contracts concurrent with the bladder neck being closed. | Alphanumeric |
Choose one |
Biering-SØrensen F, Craggs M, Kennelly M, Schick E, Wyndaele J-J. International urinary tract imaging basic spinal cord injury data set. Spinal Cord 2009;47:379-83. | Adult | Supplemental | 3.00 | 2013-07-17 09:26:36.973 | Vital Signs and Tests | Vital Signs and Other Body Measures | Assessments and Examinations |
Single Pre-Defined Value Selected |
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| C06263 | Bladder function detrusor maximum pressure value | BldrFuncDetrusorMaxPressrVal | Value of the maximum detrusor pressure on the participant/subject during filling cystometry | Value of the maximum detrusor pressure on the participant/subject during filling cystometry | Maximum detrusor pressure | Numeric Values |
Document the maximum detrusor pressure in cm H2O during filling cystometry. Up to three digits without decimals should be used. |
Biering-SØrensen F, Craggs M, Kennelly M, Schick E, Wyndaele JJ. International urodynamic basic spinal cord injury data set. Spinal Cord 2008 Jul;46(7):513-6. | Adult | Supplemental | 3.00 | 2013-07-17 09:26:36.973 | Vital Signs and Tests | Vital Signs and Other Body Measures | Assessments and Examinations |
Free-Form Entry |
centimeter of water | |||||||||
| C01521 | Heart rate | HeartRate | The participant's pulse or number of contractions (heart beats) per minute | The participant's pulse or number of contractions (heart beats) per minute | Pulse | Numeric Values |
Record the pulse of the participant/subject in beats per minute. |
Krassioukov A, Alexander MS, Karlsson AK, Donovan W, Mathias CJ, Biering-SØrensen F. International spinal cord injury cardiovascular function basic data set. Spinal Cord. 2010 Aug;48(8):586-90. | Adult;Pediatric | Supplemental | 3.10 | 2024-03-11 10:48:30.0 | Vital Signs and Tests | Vital Signs and Other Body Measures | Assessments and Examinations |
Free-Form Entry |
0 | 300 | beats per minute | 2767073 | ||||||
| C18145 | Procedure perform time | ProcedurePerformTime | Time of day at which the examination was taken measured in an hour/minute format (HHMM). | Time of day at which the examination was taken measured in an hour/minute format (HHMM). | Time performed | 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.). |
Krassioukov A, Alexander MS, Karlsson AK, Donovan W, Mathias CJ, Biering-SØrensen F. International spinal cord injury cardiovascular function basic data set. Spinal Cord. 2010 Aug;48(8):586-90. | Adult;Pediatric | Supplemental | 3.00 | 2013-07-17 09:26:36.973 | Vital Signs and Tests | Vital Signs and Other Body Measures | Assessments and Examinations |
Free-Form Entry |
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| C06122 | Renography radioactive isotope type | RengrphyRadactveistpTyp | Type of radioactive isotope used to perform the renography | Type of radioactive isotope used to perform the renography | Method used | DMSA;DTPA;Mag 3 | Technetium-99m dimercaptosuccinic acid;Technetium-99m diethylenetriamine pentaacetic acid;Technetium-99m mercaptoacetyltriglycine | Alphanumeric |
Choose one |
Biering-SØrensen F, Craggs M, Kennelly M, Schick E, Wyndaele J-J. International urinary tract imaging basic spinal cord injury data set. Spinal Cord 2009;47:379-83. | Adult | Supplemental | 3.00 | 2013-07-17 09:26:36.973 | Vital Signs and Tests | Vital Signs and Other Body Measures | Assessments and Examinations |
Single Pre-Defined Value Selected |
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| C06163 | Striated urethral sphincter during voiding status | StriatUrthSprincDurVoidStatus | Status of the striated urethral sphincter during voiding | Status of the striated urethral sphincter during voiding | Straited urethral sphincter during voiding | Normal;Closed | Normal urethral function is defined as a urethra that opens, and is continuously relaxed to allow the bladder to be emptied at a normal pressure (Abrams et al. 2002).;Detrusor sphincter dyssynergia is defined as detrusor contraction concurrent with an involuntary contraction of the urethral and/or periurethral striated muscle. Occasionally flow may be prevented altogether (Abrams et al. 2002). | Alphanumeric |
Choose one |
Biering-SØrensen F, Craggs M, Kennelly M, Schick E, Wyndaele J-J. International urinary tract imaging basic spinal cord injury data set. Spinal Cord 2009;47:379-83. | Adult | Supplemental | 3.00 | 2013-07-17 09:26:36.973 | Vital Signs and Tests | Vital Signs and Other Body Measures | Assessments and Examinations |
Single Pre-Defined Value Selected |
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| C06264 | Bladder function bladder capacity value | BldrFuncBldrCapacityVal | Value of the bladder capacity of participant/subject during cystometry | Value of the bladder capacity of participant/subject during cystometry | Cystometric bladder capacity | Numeric Values |
Document the cystometric bladder capacity in mL during filling cystometry. Up to four digits without decimals should be used. |
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 urodynamic basic spinal cord injury data set. Spinal Cord 2008 Jul;46(7):513-6. | Adult | Supplemental | 3.00 | 2013-07-17 09:26:36.973 | Vital Signs and Tests | Vital Signs and Other Body Measures | Assessments and Examinations |
Free-Form Entry |
milliliter | |||||||||
| C01522 | Height measurement | HgtMeasr | Measurement of participant's height | Measurement of participant's height | Height (or length) | Numeric Values |
Record the height (or length for the very young) of the participant/ subject. To be collected at the visit, not self-reported. Also, indicate whether height was measured in inches (in) or centimeters (cm). |
Bauman WA, Biering-SØrensen F, Krassioukov A. The international spinal cord injury endocrine and metabolic function basic data set. Spinal Cord. 2011 Oct;49(10):1068-72. doi: 10.1038/sc.2011.51. | Adult;Pediatric | Supplemental | 3.10 | 2024-02-29 15:49:20.0 | Vital Signs and Tests | Vital Signs and Other Body Measures | Assessments and Examinations |
Free-Form Entry |
0 | 400 | centimeter | 649 | ||||||
| C18146 | Laboratory procedure HDL cholesterol measurement | LabProcedHDLCholesterolMeasr | Measurement of the amount of high density lipoprotein (HDL) cholesterol in the participant's blood | Measurement of the amount of high density lipoprotein (HDL) cholesterol in the participant's blood | HDL cholesterol | Numeric Values | Bauman WA, Biering-SØrensen F, Krassioukov A. The international spinal cord injury endocrine and metabolic function basic data set. Spinal Cord. 2011 Oct;49(10):1068-72. doi: 10.1038/sc.2011.51. | Adult | Supplemental | 4.00 | 2024-02-29 15:53:42.0 | Vital Signs and Tests | Vital Signs and Other Body Measures | Assessments and Examinations |
Free-Form Entry |
0 | 500 | milligram per deciliter | ||||||||
| C06126 | Kidney right excretory function measurement | KdnyRtExcrtryFuncMeasr | The percentage of excretory function for the right kidney. The combined excretory function for the two kidneys is 100 % | The percentage of excretory function for the right kidney. The combined excretory function for the two kidneys is 100 | Right side | Numeric Values |
Document the excretory function percentage for each kidney to the nearest integer. If only one kidney is functioning, the coding will be 100 % for the functioning kidney and 0 % for the non-functioning kidney. |
Biering-SØrensen F, Craggs M, Kennelly M, Schick E, Wyndaele J-J. International urinary tract imaging basic spinal cord injury data set. Spinal Cord 2009;47:379-83. | Adult | Supplemental | 3.00 | 2013-07-17 09:26:36.973 | Vital Signs and Tests | Vital Signs and Other Body Measures | Assessments and Examinations |
Free-Form Entry |
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| C06243 | Gastrointestinal colonic transit time measurement | GastIntstnlColncTransTmMeasr | The total gastrointestinal or colonic transit time assessed by means of radioopaque markers and measured in hours. | The total gastrointestinal or colonic transit time assessed by means of radioopaque markers and measured in hours. | Total gastrointestinal or colonic transit time | Numeric Values |
Total gastrointestinal and colonic transit times are prolonged in many individuals with SCI. Transit time through the stomach and small intestine is usually just a few hours. Colonic transit time is, however, much longer. Some authors present transit times as total gastrointestinal transit time and others prefer colonic transit time. Unless multiple x-rays are taken the most correct term is total gastrointestinal transit time. Generally, transit time is prolonged throughout thecolon in individuals with supraconal SCI. In contrast individuals with conal or cauda equina lesions often have severely prolonged rectosigmoid or left colonic transit times. The intrasubjective variation remains to be studied and due to poor correlations between total gastrointestinal /colonic transit time and colorectal symptoms after SCI the clinical relevance of transit time measurement has been questioned (Leduc 2002). Future studies are needed to clarify this. Several types of radiopaque markers and protocols for determining total gastrointestinal and colonic transit times exist. However, no evidence exists to recommend one from the others. The code Unknown is used if the transit time is not determined. |
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 | Supplemental | 3.00 | 2013-07-17 09:26:36.973 | Vital Signs and Tests | Vital Signs and Other Body Measures | Assessments and Examinations |
Free-Form Entry |
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| C06265 | Bladder function post void volume value | BldrFuncPostVoidVolVal | Value for the residual bladder volume of participant/subject after cystometry | Value for the residual bladder volume of participant/subject after cystometry | Post void residual volume | Numeric Values |
Document the post void residual volume. Up to four digits without decimals should be used. |
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 urodynamic basic spinal cord injury data set. Spinal Cord 2008 Jul;46(7):513-6. | Adult;Pediatric | Supplemental | 3.00 | 2013-07-17 09:26:36.973 | Vital Signs and Tests | Vital Signs and Other Body Measures | Assessments and Examinations |
Free-Form Entry |
milliliter | |||||||||
| C01539 | Temperature measurement | TempMeasr | Measurement of the participant's/subject's body temperature | Measurement of the participant's/subject's body temperatur | Temperature measured | Numeric Values |
Record the temperature of the participant/ subject. Also indicate the scale used to capture temperature. |
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 | 2013-08-28 16:08:00.453 | Vital Signs and Tests | Vital Signs and Other Body Measures | Assessments and Examinations |
Free-Form Entry |
0 | 50 | degree Celsius | 2644401 | ||||||
| C18147 | Laboratory procedure LDL cholesterol measurement | LabProcedLDLCholesterolMeasr | Measurement of the amount of low density lipoprotein (LDL) cholesterol in the participant's blood | Measurement of the amount of low density lipoprotein (LDL) cholesterol in the participant's blood | LDL cholesterol | Numeric Values | Bauman WA, Biering-SØrensen F, Krassioukov A. The international spinal cord injury endocrine and metabolic function basic data set. Spinal Cord. 2011 Oct;49(10):1068-72. doi: 10.1038/sc.2011.51. | Adult | Supplemental | 4.00 | 2024-02-29 15:53:42.0 | Vital Signs and Tests | Vital Signs and Other Body Measures | Assessments and Examinations |
Free-Form Entry |
0 | 500 | milligram per deciliter | ||||||||
| C06145 | Vesicouretic reflux laterality type | VscrtcReflxInd | The laterality type related to reflux to the ureter observed at the right and/or the left side | The laterality type related to reflux to the ureter observed at the right and/or the left sid | Vesicoureteric reflux | Right;Left | Right;Left | Alphanumeric |
Choose one |
Biering-SØrensen F, Craggs M, Kennelly M, Schick E, Wyndaele J-J. International urinary tract imaging basic spinal cord injury data set. Spinal Cord 2009;47:379-83. | Adult | Supplemental | 4.00 | 2013-07-17 09:26:37.0 | Vital Signs and Tests | Vital Signs and Other Body Measures | Assessments and Examinations |
Single Pre-Defined Value Selected |
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| C06244 | Colonic transit right side measurement | ColncTransRtSdMeasr | The transit time of the caecum, ascending- and transverse colon assessed by means of radioopaque markers and measured in hours. | The transit time of the caecum, ascending- and transverse colon assessed by means of radioopaque markers and measured in hours. | Right colonic transit time | Numeric Values |
The physiology and innervation of the right colon (caecum, ascending colon and oral 2/3 of the transverse colon) is different from that of the left colon (splenic flexure, descending colon, and rectosigmoid). The right colon is mainly for storage and absorption and receives its parasympathetic innervation from the vagal nerve. The left colon is mainly a transit organ for defecation at receives its parasympathetic innervation from the sacral segments (S2-S4) of the spinal cord. Accordingly, colonc transit time is usually divided into right and left. Whether this is of clinical significance in SCI remains to be determined. The code Not tested is used if the transit time is not determined. |
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 | Supplemental | 3.00 | 2013-07-17 09:26:36.973 | Vital Signs and Tests | Vital Signs and Other Body Measures | Assessments and Examinations |
Free-Form Entry |
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| C06363 | Serum lipid anti lipid therapy indicator | SermLipAntLipTherpyInd | Indicates whether a fasting lipid profile was conducted while the participant/subject was on anti-lipid therapy | Indicates whether a fasting lipid profile was conducted while the participant/subject was on anti-lipid therapy | During anti-lipid therapy | Yes;No;Unknown | Yes;No;Unknown | Alphanumeric |
Choose one |
Bauman WA, Biering-SØrensen F, Krassioukov A. The international spinal cord injury endocrine and metabolic function basic data set. Spinal Cord. 2011 Oct;49(10):1068-72. doi: 10.1038/sc.2011.51. | Adult | Supplemental | 3.00 | 2013-07-17 09:26:36.973 | Vital Signs and Tests | Vital Signs and Other Body Measures | Assessments and Examinations |
Single Pre-Defined Value Selected |
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| C01541 | Weight measurement | WgtMeasr | Measurement of participant's weight | Measurement of participant's weight | Weight | Numeric Values |
Record the weight of the participant/subject. To be collected at the visit, not self-reported. Also, indicate whether weight was measured in pounds (lbs) or kilograms (kg). |
No references availableBauman WA, Biering-SØrensen F, Krassioukov A. The international spinal cord injury endocrine and metabolic function basic data set. Spinal Cord. 2011 Oct;49(10):1068-72. doi: 10.1038/sc.2011.51. | Adult;Pediatric | Supplemental | 3.10 | 2024-02-29 15:49:21.0 | Vital Signs and Tests | Vital Signs and Other Body Measures | Assessments and Examinations |
Free-Form Entry |
0 | 500 | kilogram | 2179689 | ||||||
| C18153 | Data unknown text | DataUnknwnTxt | The free-text field to Mark an "X" in to record if data are unknown or not available | The free-text field to Mark an "X" in to record if data are unknown or not availabl | Alphanumeric |
Check box for Unknown |
No references available | Adult;Pediatric | Supplemental | 3.00 | 2013-07-17 09:26:36.973 | Vital Signs and Tests | Vital Signs and Other Body Measures | Assessments and Examinations | 20 |
Free-Form Entry |
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| C06147 | Bladder diverticulum indicator | BldrDvrtclmInd | Indicator of whether there is bladder diverticulum. This means diverticula of any size within the bladder or bladder neck were found | Indicator of whether there is bladder diverticulum. This means diverticula of any size within the bladder or bladder neck were foun | Bladder diverticulum | Bladder diverticulum | Bladder diverticulum | Alphanumeric |
Choose one |
Biering-SØrensen F, Craggs M, Kennelly M, Schick E, Wyndaele J-J. International urinary tract imaging basic spinal cord injury data set. Spinal Cord 2009;47:379-83. | Adult | Supplemental | 3.00 | 2013-07-17 09:26:36.973 | Vital Signs and Tests | Vital Signs and Other Body Measures | Assessments and Examinations |
Single Pre-Defined Value Selected |
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| C06252 | Compression device type | ComprsnDevTyp | Any compression device worn by the individual that may affect cardiovascular parameters during the examination. | Any compression device worn by the individual that may affect cardiovascular parameters during the examination. | Devices in use during testing | Abdominal binder;Pressure stockings;None;Unknown | Abdominal binder;Pressure stockings;None;Unknown | Alphanumeric |
The wearing of compression devices (abdominal binder or pressure stockings) could affect cardiovascular parameters during the examination. Therefore, their use during the examination should be documented. |
Krassioukov A, Alexander MS, Karlsson AK, Donovan W, Mathias CJ, Biering-SØrensen F. International spinal cord injury cardiovascular function basic data set. Spinal Cord. 2010 Aug;48(8):586-90. <br />Hopman,M.T., Monroe,M., Dueck,C., Phillips,W.T. & Skinner,J.S. Blood redistribution and circulatory responses to submaximal arm exercise in persons with spinal cord injury. Scand. J. Rehabil. Med. 30, 167-174 (1998). | Adult | Supplemental | 3.00 | 2013-07-17 09:26:36.973 | Vital Signs and Tests | Vital Signs and Other Body Measures | Assessments and Examinations |
Single Pre-Defined Value Selected |
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| C06416 | Colonic transit left side measurement | ColncTransLftSdMeasr | The transit time of the descending colon (including the splenic flexure) and the rectosigmoid assessed by means of radioopaque markers and measured in hours. | The transit time of the descending colon (including the splenic flexure) and the rectosigmoid assessed by means of radioopaque markers and measured in hours. | Left colonic transit time | Numeric Values |
The physiology and innervation of the right colon (caecum, ascending colon and oral 2/3 of the transverse colon) is different from that of the left colon (splenic flexure, descending colon, and rectosigmoid). The right colon is mainly for storage and absorption and receives its parasympathetic innervation from the vagal nerve. The left colon is mainly a transit organ for defecation at receives its parasympathetic innervation from the sacral segments (S2-S4) of the spinal cord. Accordingly, colonc transit time is usually divided into right and left. Whether this is of clinical significance in SCI remains to be determined. The code Not tested is used if the transit time is not determined. |
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 | Supplemental | 3.00 | 2013-07-17 09:26:36.973 | Vital Signs and Tests | Vital Signs and Other Body Measures | Assessments and Examinations |
Free-Form Entry |
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| C01553 | Blood pressure measurement position type | BldPressrMeasrPositionTyp | Indicator of the participant's position during the blood pressure measurement | Indicator of the participant's position during the blood pressure measurement | Position during testing | Sitting;Supine;Unknown | Sitting;Supine;Unknown | Alphanumeric |
Record the position the participant/ subject was in when the blood pressure was measured. |
No references availableKrassioukov A, Alexander MS, Karlsson AK, Donovan W, Mathias CJ, Biering-SØrensen F. International spinal cord injury cardiovascular function basic data set. Spinal Cord. 2010 Aug;48(8):586-90. | Adult;Pediatric | Supplemental | 3.10 | 2024-03-11 10:47:19.0 | Vital Signs and Tests | Vital Signs and Other Body Measures | Assessments and Examinations |
Single Pre-Defined Value Selected |
2008432 | |||||||
| C18168 | Laboratory procedure total cholesterol measurement | LabProcedTotalCholesterolMeasr | Measurement of the total amount of cholesterol in the participant's blood | Measurement of the total amount of cholesterol in the participant's blood | Total cholesterol (TC) | Numeric Values | Bauman WA, Biering-SØrensen F, Krassioukov A. The international spinal cord injury endocrine and metabolic function basic data set. Spinal Cord. 2011 Oct;49(10):1068-72. doi: 10.1038/sc.2011.51. | Adult | Supplemental | 4.00 | 2024-02-29 15:53:43.0 | Vital Signs and Tests | Vital Signs and Other Body Measures | Assessments and Examinations |
Free-Form Entry |
milligrams per deciliter | ||||||||||
| C06149 | Bladder neck rest status | BldrNckRstStatus | Bladder neck is evaluated to be either open or closed at rest | Bladder neck is evaluated to be either open or closed at res | Bladder neck at rest | Open;Closed | Open;Closed | Alphanumeric |
Choose one |
Biering-SØrensen F, Craggs M, Kennelly M, Schick E, Wyndaele J-J. International urinary tract imaging basic spinal cord injury data set. Spinal Cord 2009;47:379-83. | Adult | Supplemental | 3.00 | 2013-07-17 09:26:36.973 | Vital Signs and Tests | Vital Signs and Other Body Measures | Assessments and Examinations |
Single Pre-Defined Value Selected |
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| C06253 | Heart rate status | HeartRateStatus | Findings after taking a participant's pulse during the examination | Findings after taking a participant's pulse during the examinatio | Pulse | Regular;Irregular | Regular;Irregular | Alphanumeric |
Choose one. Both abnormal heart rate and rhythm are commonly observed in individuals with cervical and high thoracic spinal cord lesions. |
Krassioukov A, Alexander MS, Karlsson AK, Donovan W, Mathias CJ, Biering-SØrensen F. International spinal cord injury cardiovascular function basic data set. Spinal Cord. 2010 Aug;48(8):586-90. Claydon,V.E., Elliott,S.L., Sheel,A.W. & Krassioukov,A. Card | Adult | Supplemental | 3.00 | 2013-07-17 09:26:36.973 | Vital Signs and Tests | Vital Signs and Other Body Measures | Assessments and Examinations |
Single Pre-Defined Value Selected |
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| C18123 | Xray study urinary tract global result type | XrayStdyUrnTctGlblResltNormInd | The result type related to the X-ray study of the urinary tract found functional and anatomical conditions | The result type related to the X-ray study of the urinary tract found functional and anatomical condition | X-ray of the urinary tract – Kidney Ureter Bladder (KUB) | Normal;Kidney stone;Stone in ureter;Bladder stone;Other findings | Normal;Kidney stone;Stone in ureter;Bladder stone;Other findings | Alphanumeric |
Normal: Normal anatomical conditions werefound at the investigation; in particular, no stones in the kidneys, ureters or bladder. |
Biering-SØrensen F, Craggs M, Kennelly M, Schick E, Wyndaele J-J. International urinary tract imaging basic spinal cord injury data set. Spinal Cord 2009 May;47(5):379-83. | Adult;Pediatric | Supplemental | 4.00 | 2013-07-17 09:26:37.0 | Vital Signs and Tests | Vital Signs and Other Body Measures | Assessments and Examinations |
Single Pre-Defined Value Selected |
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| C01554 | Oxygen saturation measurement | O2SatMeasr | Value, as a percent, of baseline O2 saturation (SPO2) in nocturnal oximetry, as part of Nocturnal Oximetry | Value, as a percent, of baseline O2 saturation (SPO2) in nocturnal oximetry, as part of Nocturnal Oximetr | Oxygen saturation (%) | Numeric Values |
The suggested range is 0-100. Add date stamp for when assessed. Recommended for collection on admission and daily as required by protocol. |
No references available | Adult;Pediatric | Supplemental | 3.00 | 2013-07-22 16:57:17.79 | Vital Signs and Tests | Vital Signs and Other Body Measures | Assessments and Examinations |
Free-Form Entry |
0 | 100 | percent | |||||||
| C18169 | Laboratory procedure triglycerides measurement | LabProcedTriglyceridesMeasr | Measurement of the amount of triglycerides in the participant's blood | Measurement of the amount of triglycerides in the participant's blood | Triglycerides (TG) | Numeric Values | Bauman WA, Biering-SØrensen F, Krassioukov A. The international spinal cord injury endocrine and metabolic function basic data set. Spinal Cord. 2011 Oct;49(10):1068-72. doi: 10.1038/sc.2011.51. | Adult | Supplemental | 4.00 | 2024-02-29 15:53:45.0 | Vital Signs and Tests | Vital Signs and Other Body Measures | Assessments and Examinations |
Free-Form Entry |
milligrams per deciliter | ||||||||||
| C06150 | Urography method type | UrgrphyMethdTyp | Identifies which methods were performed on the urinary tract | Identifies which methods were performed on the urinary tract | Method used | Intravenous pyelography/Urography;CT urography;Ultrasound of the urinary tract | Intravenous pyelography/Urography;CT urography;Ultrasound of the urinary tract | Alphanumeric |
Choose one. If more than one method was performed on the same date then enter the results separately. |
Biering-SØrensen F, Craggs M, Kennelly M, Schick E, Wyndaele J-J. International urinary tract imaging basic spinal cord injury data set. Spinal Cord 2009;47:379-83. | Adult | Supplemental | 3.00 | 2013-07-17 09:26:36.973 | Vital Signs and Tests | Vital Signs and Other Body Measures | Assessments and Examinations |
Single Pre-Defined Value Selected |
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| C06258 | Bladder function bladder sensation type | BldrFuncBldrSensationTyp | Documents the bladder sensation during filling cystometry. Although the bladder sensation is assessed during filling cystometry the assumption that it is sensation from the bladder alone, without urethral or pelvic components may be false (Abrams et al. 2002). Normal bladder sensation can be judged by three defined points noted during filling cystometry and evaluated in relation to the bladder volume at that moment and in relation to the patient's symptomatic complaints | Type of bladder sensation of the participant/subject during filling cystometry | Bladder sensation during filling cystometry | Normal;Increased;Reduced;Absent;Non-specific;Unknown | Can be judged by three defined points noted (see CDE instructions) during filling cystometry and evaluated in relation to the bladder volume at that moment and in relation to the patient's symptomatic complaints.;Bladder sensation is defined, during filling cystometry, as an early first sensation of bladder filling (or an early desire to void) and/or an early strong desire to void, which occurs at low bladder volume and which persists.;Is defined, during filling cystometry, as diminished sensation throughout bladder filling.;Bladder sensation means that, during filling cystometry, the individual has no bladder sensation.;Bladder sensation, during filling cystometry, may make the individual aware of bladder filling, for example, abdominal fullness or vegetative symptoms.;Is used if the observation regarding bladder sensation during filing cystometry is not available. | Alphanumeric |
Choose one. The three defined points noted during filling cystometry are as follows: 1. First sensation of bladder filling is the feeling the patient has, during filling cystometry, when he/she first becomes aware of the bladder filling. 2. First desire to void is defined as the feeling, during filling cystometry, that would lead the patient to pass urine at the next convenient moment, but voiding can be delayed if necessary. 3. Strong desire to void this is defined, during filling cystometry, as a persistent desire to void without the fear of leakage. |
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 urodynamic basic spinal cord injury data set. Spinal Cord 2008 Jul;46(7):513-6. | Adult | Supplemental | 3.00 | 2013-07-17 09:26:36.973 | Vital Signs and Tests | Vital Signs and Other Body Measures | Assessments and Examinations |
Single Pre-Defined Value Selected |
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| C18127 | Xray urinary tract other finding text | XrayUrnTrctOthFindInd | Free-text field to specify other findings from the urinary tract X-ray study | Free-text field to specify other findings from the urinary tract X-ray stud | Other findings | Alphanumeric |
Findings of any specific deviations from the normal state not documented above can be stated in a text-field, from where it will be possible to retrieve more detailed data whenever necessary. Because many possible findings exist, it is not practical to give an exact list of findings. |
Biering-SØrensen F, Craggs M, Kennelly M, Schick E, Wyndaele J-J. International urinary tract imaging basic spinal cord injury data set. Spinal Cord 2009;47:379-83. | Adult;Pediatric | Supplemental | 4.00 | 2013-07-17 09:26:37.0 | Vital Signs and Tests | Vital Signs and Other Body Measures | Assessments and Examinations | 255 |
Free-Form Entry |
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| C01565 | Blood pressure systolic measurement | BldPressrSystMeasr | Measurement of pressure of the participant's blood against the artery walls during systole (the contraction phase) in millimeters of mercury (mmHg) | Measurement of pressure of the participant's blood against the artery walls during systole (the contraction phase) in millimeters of mercury (mmHg) | Blood Pressure | Numeric Values |
Record the systolic blood pressure of the participant/ subject. The standard unit for measuring blood pressure is mmHg, which is approximately equivalent to Torr. |
No references availableKrassioukov A, Alexander MS, Karlsson AK, Donovan W, Mathias CJ, Biering-SØrensen F. International spinal cord injury cardiovascular function basic data set. Spinal Cord. 2010 Aug;48(8):586-90. | Adult;Pediatric | Supplemental | 3.10 | 2024-03-11 10:40:09.0 | Vital Signs and Tests | Vital Signs and Other Body Measures | Assessments and Examinations |
Free-Form Entry |
0 | 300 | millimeter of mercury | 2004289 | C25298 | |||||
| C18608 | Kidney left excretory function measurement | KdnyLtExcrtryFuncMeasr | The percentage of excretory function for the left kidney. The combined excretory function for the two kidneys is 100 % | The percentage of excretory function for the left kidney. The combined excretory function for the two kidneys is 100 | Left side | Numeric Values |
Document the excretory function percentage for each kidney to the nearest integer. If only one kidney is functioning, the coding will be 100 % for the functioning kidney and 0 % for the non-functioning kidney. |
Biering-SØrensen F, Craggs M, Kennelly M, Schick E, Wyndaele J-J. International urinary tract imaging basic spinal cord injury data set. Spinal Cord 2009;47:379-83. | Adult | Supplemental | 1.00 | 2013-08-29 00:00:00.0 | Vital Signs and Tests | Vital Signs and Other Body Measures | Assessments and Examinations |
Free-Form Entry |
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| C06152 | Imaging study urinary tract global result type | ImgStdyUrnTrctGlblResltNormInd | The type of results related to urinary tract from imaging of two kidneys | The type of results related to urinary tract from imaging of two kidney | Result | Normal;Stasis/dilatation in upper urinary tract;Kidney stone;Stone in ureter;Bladder stone;Other findings | Normal;Stasis/dilatation in upper urinary tract;Kidney stone;Stone in ureter;Bladder stone;Other findings | Alphanumeric |
Choose one |
Biering-SØrensen F, Craggs M, Kennelly M, Schick E, Wyndaele J-J. International urinary tract imaging basic spinal cord injury data set. Spinal Cord 2009;47:379-83. | Adult | Supplemental | 4.00 | 2013-07-17 09:26:37.0 | Vital Signs and Tests | Vital Signs and Other Body Measures | Assessments and Examinations |
Single Pre-Defined Value Selected |
