Data Collection Form. American Society of Nuclear Cardiology (ASNC) Patient & Procedure Information. Indications

Transcription

1 Data Collection Form American Society of Nuclear Cardiology (ASNC) Patient & Procedure Information Site ID 901* : Study GUID 1* : <auto-generated> MRN 2* : DOB 3 : / / Patient Zip Code 4 : Sex 5 : Male Female Unknown Patient Hospitalized 6 : Ambulatory Inpatient Observation/ER Unknown Study Completion Date/Time 7* : / / : Weight 8 : kg Height 9 : cm Race(s) 10 : (check all that apply) White Black/African American Asian Hispanic/Latino Descent 11 : Yes No American Indian/Alaska Native Native Hawaiian/Pacific Islander Insurance Payer 12 : Indian Health Service Medicaid Medicare FFS Medicare Advantage Military Health Care (check all that apply) Non-US Insurance Private Health Insurance State Specific Plan (Non-Medicaid) None Referring MD/DO - First Name 13 : Middle 14 : Last 15 : NPI 16 : Interpreting MD/DO - First Name 17 : Middle 18 : Last 19 : NPI 20* : Vendor ID(s) 21 : Quantitative Package Provider ID 22 : Cedars-Sinai Digisonics GE INVIA Philips Positron Siemens Syntermed Generic Other Quantitative Software Package Name 23 : Camera Used for Imaging Study 24 : Location of the Imaging Study 25 : Indications Primary 26 : (select one) Abnormal Electrocardiogram Abnormal Stress Test Angina or Anginal Equivalent Assessment of symptoms suspected of cardiac etiology Assessment of ventricular function Cardiac morphology (including cardiac mass) Congenital Heart Disease Coronary Artery Disease Coronary Risk Factors Evaluation for cardiomyopathy Evaluation for valvular heart disease Heart Failure History of CABG History of PCI Initial detection/risk assessment of CAD Secondary 29 : (check all that apply) Abnormal Electrocardiogram Abnormal Stress Test Angina or Anginal Equivalent Assessment of symptoms suspected of cardiac etiology Assessment of ventricular function Cardiac morphology (including cardiac mass) Congenital Heart Disease Coronary Artery Disease Coronary Risk Factors Evaluation for cardiomyopathy Evaluation for valvular heart disease Heart Failure History of CABG History of PCI Initial detection/risk assessment of CAD American Society of Nuclear Cardiology 9/1/2015 v1.0 Page 1 of 5

2 Palpitations Pericardial disease Preoperative evaluation within 30 days preceding low-risk non-cardiac surgery Type of Surgery 27 : Syncope Viability Not provided Other, Reason 28 : Palpitations Pericardial disease Preoperative evaluation within 30 days preceding low-risk non-cardiac surgery Type of Surgery 30 : Syncope Viability Not provided Other, Reason 31 : Pretest Chest Pain 32 : Anginal Equivalent Atypical Angina No Chest Pain Nonanginal Chest Pain Typical Angina Appropriate Use Criteria 33 : Appropriate May be appropriate Most Recent PCI Date 34 : / / Rarely appropriate Stress Test & Rest Information Stress Test Type 35 : Exercise Mental Stress Pharmacologic Pharmacologic/Exercise Rest Other, Type 36 : Pharmacologic Stress Agent 37 : Adenosine Atropine Dipyridamole Dobutamine Dobutamine with Atropine Regadenoson Other, Agent 38 : Indication for Pharmacologic Stress 39 : Left Bundle Branch Block (LBBB) or Pacemaker PET Unable to exercise Other, Indication 40 : Exercise Protocol 41 : Arm Ergometry Bicycle Ergometer Bruce Low Level Mental Stress Modified Bruce Modified Naughton Naughton Ramp Other, Exercise Protocol 42 : Stress HR 43 : bpm Stress BP Systolic 44 : mmhg Stress BP Diastolic 45 : mmhg Exercise Duration 46 : : mm:ss Anginal Stress Symptoms 47 : Anginal Equivalent Atypical Angina No Chest Pain Nonanginal Chest Pain Typical Angina Resting HR - Standing 48 : bpm Resting BP Systolic 49 : mmhg Resting BP Diastolic 50 : mmhg ECG Interpretable 51 : Interpretable for Ischemia Not Interpretable for Ischemia Unknown Maximum ST-Segment Change 52 : mm Imaging Protocol 53 : Rest Only Rest/Delayed Rest Rest/Stress 1-Day Rest/Stress 2-Day Stress only Stress/Rest 1-day Stress/Rest 2-day Other, Protocol 54 : Stress Radiopharmaceutical 55 : N13-Ammonia Rb-82 Tc-99m Tetrofosmin Tc-99m Sestamibi Thallium-201 F-18 FDG Stress Dose 56 : mci Stress Image Date and Time 57 : / / : Rest Radiopharmaceutical 58 : I-123 N13-Ammonia Rb-82 Tc-99m Tetrofosmin Tc-99m Sestamibi Thallium-201 F-18 FDG Rest Dose 59 : mci Rest Image Date and Time 60 : / / : Attenuation Correction Type 61 : Computed Tomography (CT) Scan None Transmission Other, Type 62 : Reasons for Termination Primary 63 : (Select one) Secondary 65 : (check all that apply) CNS Symptoms CNS Symptoms Conduction Abnormalities Conduction Abnormalities Drop in Systolic Blood Pressure Drop in Systolic Blood Pressure American Society of Nuclear Cardiology 9/1/2015 v1.0 Page 2 of 5

3 ECG Changes End of Protocol Fatigue Increasing Chest Pain Leg pain Moderate to Severe Angina Mortality Non-Central Nervous System (CNS) Symptoms Patient Request Procedure Related Complication Reached Target HR Signs of Poor Perfusion Technical Problems Other, Reason 64 : ECG Changes End of Protocol Fatigue Increasing Chest Pain Leg pain Moderate to Severe Angina Mortality Non-Central Nervous System (CNS) Symptoms Patient Request Procedure Related Complication Reached Target HR Signs of Poor Perfusion Technical Problem Other, Reason 66 : STRESS RESULTS - 17 SEGMENTS: (Note: Normal (0%), Mild (> 0 and < 10%), Moderate (>= 10 and < 20%), Severe (>= 20%)) 1-Basal Anterior 67 : Normal Mild Moderate Severe Background Radiation 2-Basal Anteroseptal 68 : Normal Mild Moderate Severe Background Radiation 3-Basal Inferoseptal 69 : Normal Mild Moderate Severe Background Radiation 4-Basal Inferior 70 : Normal Mild Moderate Severe Background Radiation 5-Basal Inferolateral 71 : Normal Mild Moderate Severe Background Radiation 6-Basal Anterolateral 72 : Normal Mild Moderate Severe Background Radiation 7-Mid Anterior 73 : Normal Mild Moderate Severe Background Radiation 8-Mid Anteroseptal 74 : Normal Mild Moderate Severe Background Radiation 9-Mid Inferoseptal 75 : Normal Mild Moderate Severe Background Radiation 10-Mid Inferior 76 : Normal Mild Moderate Severe Background Radiation 11-Mid Inferolateral 77 : Normal Mild Moderate Severe Background Radiation 12-Mid Anterolateral 78 : Normal Mild Moderate Severe Background Radiation 13-Apical Anterior 79 : Normal Mild Moderate Severe Background Radiation 14-Apical Septal 80 : Normal Mild Moderate Severe Background Radiation 15-Apical Inferior 81 : Normal Mild Moderate Severe Background Radiation 16-Apical Lateral 82 : Normal Mild Moderate Severe Background Radiation 17-Apex 83 : Normal Mild Moderate Severe Background Radiation REST RESULTS - 17 SEGMENTS: (Note: Normal (0%), Mild (> 0 and < 10%), Moderate (>= 10 and < 20%), Severe (>= 20%)) 1-Basal Anterior 84 : Normal Mild Moderate Severe Background Radiation 2-Basal Anteroseptal 85 : Normal Mild Moderate Severe Background Radiation 3-Basal Inferoseptal 86 : Normal Mild Moderate Severe Background Radiation 4-Basal Inferior 87 : Normal Mild Moderate Severe Background Radiation 5-Basal Inferolateral 88 : Normal Mild Moderate Severe Background Radiation 6-Basal Anterolateral 89 : Normal Mild Moderate Severe Background Radiation 7-Mid Anterior 90 : Normal Mild Moderate Severe Background Radiation 8-Mid Anteroseptal 91 : Normal Mild Moderate Severe Background Radiation American Society of Nuclear Cardiology 9/1/2015 v1.0 Page 3 of 5

4 9-Mid Inferoseptal 92 : Normal Mild Moderate Severe Background Radiation 10-Mid Inferior 93 : Normal Mild Moderate Severe Background Radiation 11-Mid Inferolateral 94 : Normal Mild Moderate Severe Background Radiation 12-Mid Anterolateral 95 : Normal Mild Moderate Severe Background Radiation 13-Apical Anterior 96 : Normal Mild Moderate Severe Background Radiation 14-Apical Septal 97 : Normal Mild Moderate Severe Background Radiation 15-Apical Inferior 98 : Normal Mild Moderate Severe Background Radiation 16-Apical Lateral 99 : Normal Mild Moderate Severe Background Radiation 17-Apex 100 : Normal Mild Moderate Severe Background Radiation SUMMARY STRESS PERFUSION DEFECTS: (specify up to 5 defects) 1. Location 101 : Severity 102 : Mild (< 10%) Moderate (>=10% and < 20%) Severe (>= 20%) Size 103 : Small (1-2 segments) Medium (3-4 segments) Large (5+ segments) Type 104 : Mixed Persistent Reversible 2. Location 105 : Severity 106 : Mild (<10%) Moderate (>=10% and < 20%) Severe (>=20%) Size 107 : Small (1-2 segments) Medium (3-4 segments) Large (5+ segments) Type 108 : Mixed Persistent Reversible 3. Location 109 : Severity 110 : Mild (<10%) Moderate (>=10% and < 20%) Severe (>=20%) Size 111 : Small (1-2 segments) Medium (3-4 segments) Large (5+ segments) Type 112 : Mixed Persistent Reversible 4. Location 113 : Severity 114 : Mild (<10%) Moderate (>=10% and < 20%) Severe (>=20%) Size 115 : Small (1-2 segments) Medium (3-4 segments) Large (5+ segments) Type 116 : Mixed Persistent Reversible 5. Location 117 : Severity 118 : Mild (<10%) Moderate (>=10% and < 20%) Severe (>=20%) Size 119 : Small (1-2 segments) Medium (3-4 segments) Large (5+ segments) Type 120 : Mixed Persistent Reversible Transient Ischemic Dilation (TID) 121 : No Yes Lung Uptake Stress Only 122 : No Yes Left Ventricular Ejection Fraction at Rest Post Stress 123 : % End-Systolic Volume at Rest Post Stress 124 : ml End-Diastolic Volume at Rest Post Stress 123 : ml Overall Study Quality 126 : Excellent Good Fair Poor Other, Study Quality 127 : Left Ventricular Perfusion Summary 128 : Abnormal Infarction Abnormal Ischemia Abnormal mixed ischemia and infarction Equivocal Normal Probably Normal Uninterpretable Left Ventricular Function Summary 129 : Abnormal Equivocal Normal Uninterpretable Interpretation Date/Time 130 : / / : Signature Date/Time 131 : / / : American Society of Nuclear Cardiology 9/1/2015 v1.0 Page 4 of 5

5 Comments 132 : ABOUT THIS FORM: The purpose of this document is to depict all data elements included in the ImageGuide data registry and to serve as a sample user interface for the reporting vendors. This form will not be used to collect and submit data to the registry. The form depicts all data elements as defined in the Data Dictionary. Also included are the selections for each data element, element relationships (i.e., ), data types (e.g., free text, categorical, continuous, date, date/time), required elements and coding instructions (e.g., select one, check all that apply). The bolded data elements are defined as unique elements in the Data Dictionary. The selections, or permissible values, for each data element are denoted with a (i.e., radio button). A radio button implies that only a single selection can be made for that element. The symbol indicates a check box. Multiple check box selections may be made unless otherwise noted American Society of Nuclear Cardiology 9/1/2015 v1.0 Page 5 of 5