ARC Schema

The ARC schema is made available as a machine-readable CSV (also as a HTML table at the bottom of this page) of clinical and research questions. This file provides the standardized structure that ensures interoperability across studies and outbreak contexts.

Each row in the CSV represents a variable used in the Case Report Forms (CRFs). Variables include metadata that ensures clarity, interoperability, and reusability across contexts. For more details on variable naming conventions see this, and for details on the variable data types see this.

For every variable, the following fields are included:

  • Variable: Unique variable name identifier used in the dataset (e.g., comor_hypertensi).

  • Form: The CRF form where the variable appears (e.g., Presentation, Daily, Outcome, …).

  • Section: Subdivision within the form that groups related questions (e.g., Co-morbidities and Risk Factors,…).

  • Type: Format of the response field (e.g., radio, checkbox, text, date).

  • Question: Human-readable text shown to the data collector (e.g., Hypertension).

  • Answer Options: Permissible responses to the question. These may reference predefined lists in /Lists (e.g., 1, Yes | 0, No | 99, Unknown).

  • Validation: Input rules for the response, such as numeric range or pattern restrictions.

  • Minimum / Maximum: Boundaries for numeric input when applicable.

  • List: Links to option lists in /Lists.

  • Skip Logic: Rules defining when the variable should be displayed, depending on other responses.

  • Body System: Physiological system the variable belongs to (e.g., Cardiovascular).

  • Definition: Description of the concept being captured, often linked to clinical definitions.

  • Completion Guideline: Instruction text for data collectors to standardize responses.

  • Standardized Term Codelist: Reference ontology or terminology system used for harmonization (e.g., SNOMED).

  • Standardized Term Code: The specific code(s) from the ontology (e.g., 38341003, Hypertensive disorder, systemic arterial (disorder)).

  • Templates / Presets: Links to where the variable is used in disease-specific CRFs (COVID, Dengue, Mpox, H5Nx, ARI) or risk scores (Charlson CI, mSOFA).

The CSV serves not only as a question bank, but also as a metadata dictionary that enables:

  • Harmonized clinical data collection.

  • Mapping to standard vocabularies.

  • Adaptation for different diseases and study contexts.

The raw CSV is presented below as a HTML table - the display is cut off to the right but you can scroll across the table using the touchpad.

Form

Section

Variable

Type

Question

Answer Options

Validation

Minimum

Maximum

List

Skip Logic

Body System

Definition

Completion Guideline

Standardized Term Codelist

Standardized Term Code

Metathesaurus

Identifier

Research Category

preset_ARChetype Disease CRF_Covid

preset_ARChetype Disease CRF_H5Nx

preset_ARChetype Disease CRF_Dengue

preset_ARChetype Disease CRF_Chikungunya

preset_ARChetype Disease CRF_Mpox

preset_ARChetype Disease CRF_Mpox Pregnancy and Paediatric

preset_ARChetype Syndromic CRF_ARI

preset_ARChetype Syndromic CRF_Arbovirus

preset_Score_CharlsonCI

preset_Score_mSOFA

preset_Score_mSOFA_Dengue

preset_Recommended Outcomes_Dengue

preset_Populations_Paediatric

preset_Populations_Pregnancy

preset_User Generated CRF_Encephalitis

presentation

subjid

text

Participant Identification Number (PIN)

The Participant Identification Number or PIN is a unique number used to identify the patient’s (participant’s) data.

Write the Participant Identification Number (PIN).

1

1

1

1

1

1

1

1

1

presentation

INCLUSION CRITERIA

inclu_disease

user_list

Suspected or confirmed infection

inclusion_Diseases

This refers to any suspected or confirmed infection(s).

If more than one infection is suspected, select the most likely and complete the PATHOGEN TESTING section with laboratory confirmation.

1

1

1

1

1

1

1

1

presentation

INCLUSION CRITERIA

inclu_reason

radio

Is the suspected or confirmed infection the reason for hospital admission?

1, Yes | 0, No | 99, Unknown

This refers to whether suspected or confirmed infection with the pathogen of interest if the reason (indication) for the hospital admission.

Indicate ‘Yes’ if suspected or confirmed infection with the pathogen of interest if the reason (indication) for the hospital admission. Indicate ‘No’ if the suspected or confirmed infection with the pathogen of interest is not the reason (indication) for hospital admission.

1

1

1

1

presentation

INCLUSION CRITERIA

inclu_case

radio

Status of case

1, Confirmed | 2, Probable | 3, Suspected | 4, Discarded | 5, Error

Confirmed refers to a case that is laboratory confirmed and may fulfil the clinical criteria as described in the case definition. Probable refers to a clinically compatible illness that is epidemiologically linked to a confirmed case without laboratory confirmation of infection with pathogen of interest. Suspected refers to a clinically compatible illness without epidemiological link or laboratory confirmation. Discarded refers to a patient with a negative laboratory test and has failed to fulfil the criteria for a suspect, probable or confirmed case.

Select the most appropriate option that represents the status of the case.

1

1

1

presentation

INCLUSION CRITERIA

inclu_testreason

radio

Reason why the patient was tested

1, Symptomatic | 2, Asymptomatic, contact-traced | 3, Asymptomatic, mass testing campaign | 4, Not tested | 99, Unknown | 88, Other

This refers to the reason the patient was tested for the pathogen of interest.

Select the most appropriate option which corresponds to the reason the patient was tested for the pathogen of interest.

1

1

presentation

INCLUSION CRITERIA

inclu_testreason_otth

text

Specify other reason

[inclu_testreason]=’88’

This refers to the reason the patient was tested for the pathogen of interest.

Select the most appropriate option which corresponds to the reason the patient was tested for the pathogen of interest.

1

1

presentation

INCLUSION CRITERIA

inclu_consentdes

descriptive

Consent:

presentation

INCLUSION CRITERIA

inclu_consent

radio

Participant (or their representative) has provided consent to participate in this study.

1, Yes | 0, No, participant did not agree to participate in the study | 2, No, the ethics committee approved a waiver of consent | 99, Unknown

This refers to provision of informed consent by the patient or their representative for participation in this study.

Indicate ‘Yes’ if the patient or their representative has provided their informed consent for participation in this study.

SNOMED

61861000000100, Consent (record artifact)

C5702721, Consent (record artifact)

presentation

INCLUSION CRITERIA

inclu_consent_date

date_dmy

Date of consent

date_dmy

today

[inclu_consent]=’1’

This refers to date on which informed consent was given for the participants inclusion in this study.

Enter the date on which informed consent was given for the participants inclusion in this study. (Use the format DD/MM/YYYY)

C2985782, Informed Consent Date

presentation

INCLUSION CRITERIA

inclu_consent_who

radio

Consent provided by

1, Participant | 2, Parent/guardian | 3, Consultee | 4, Independent clinician

[inclu_consent]=’1’

This refers to who provided the consent for participation in this study.

Select the most appropriate option that represents who provided the consent for participation in this study.

presentation

INCLUSION CRITERIA

inclu_consent_whopg

radio

Does the child or young person give their assent?

1, Yes | 0, No | 2, Not competent

[inclu_consent_who]=’2’

This refers to assent given by a minor or adult who is unable to give consent on their own behalf, to participate in a study. Assent must be accompanied by consent from a parent or legal guardian for full participation in the study.

Select the most appropriate option that represents whether assent was provided for participation in this study.

C5205794, Informed Assent

presentation

INCLUSION CRITERIA

inclu_consent2des

descriptive

Secondary use of data collected, the participant agreed with the following statements:

[inclu_consent]=’1’

presentation

INCLUSION CRITERIA

inclu_consent_secrsch

radio

Future use of pseudonymised data in ethically approved research, including research in other countries

1, Yes | 0, No

[inclu_consent]=’1’

Refers to consent for future secondary use of pseudonymised data in ethically approved research

This is an optional consent question and is not required for completion of the remaining CRF.

presentation

INCLUSION CRITERIA

inclu_consent_secprod

radio

Future use of pseudonymised data to manufacture tests, treatments or other products, including commercial products

1, Yes | 0, No

[inclu_consent]=’1’

Refers to consent for future secondary use of pseudonymised data to manufacture tests, treatments or other products, including commercial products

This is an optional consent question and is not required for completion of the remaining CRF.

presentation

INCLUSION CRITERIA

inclu_consent_secgen

radio

Future use of pseudonymised genetic data in ethically approved research, including research in other countries

1, Yes | 0, No

[inclu_consent]=’1’

Refers to consent for future secondary use of pseudonymised genetic data in ethically approved research

This is an optional consent question and is not required for completion of the remaining CRF.

presentation

INCLUSION CRITERIA

inclu_consentsecsamp

descriptive

Secondary use of samples collected, the participant agreed with the following statements:

[inclu_consent]=’1’

presentation

INCLUSION CRITERIA

inclu_consent_secsamprsch

radio

Future use of pseudonymised samples in ethically approved research, including research in other countries

1, Yes | 0, No

[inclu_consent]=’1’

Refers to consent for future secondary use of pseudonymised samples in ethically approved research, including research in other countries

This is an optional consent question and is not required for completion of the remaining CRF.

presentation

INCLUSION CRITERIA

inclu_consent_secsampprod

radio

Future use of pseudonymised samples or materials or data derived from those samples to manufacture tests, treatments or other products, including commercial products

1, Yes | 0, No

[inclu_consent]=’1’

Refers to consent for future secondary use of pseudonymised samples or materials or data derived from those samples to manufacture tests, treatments or other products, including commercial products

This is an optional consent question and is not required for completion of the remaining CRF.

presentation

INCLUSION CRITERIA

inclu_consent_secsampgen

radio

Future use of pseudonymised genetic samples in ethically approved research, including research in other countries

1, Yes | 0, No

[inclu_consent]=’1’

Refers to consent for future secondary use of pseudonymised genetic samples in ethically approved research, including research in other countries

This is an optional consent question and is not required for completion of the remaining CRF.

presentation

INCLUSION CRITERIA

inclu_consentcont

descriptive

Contact

[inclu_consent]=’1’

presentation

INCLUSION CRITERIA

inclu_consent_contnstudy

radio

To be contacted to participate in future work, including research studies

1, Yes | 0, No

[inclu_consent]=’1’

Refers to contact to be contacted to participate in future work, including research studies

This is an optional consent question and is not required for completion of the remaining CRF.

presentation

ONSET & PRESENTATION

pres_onsetdate

date_dmy

Onset date of first / earliest symptom

date_dmy

today

This refers to the date of onset of the first / earliest symptom which is clinically related to the current episode of illness.

Enter the date of the first symptom that you clinically believe was related to this episode of illness. (Use the format DD/MM/YYYY)

SNOMED

405795006, Time of symptom onset (observable entity)

1

1

1

1

1

1

1

1

1

presentation

ONSET & PRESENTATION

pres_symptpres

radio

Symptomatic at initial presentation?

1, Yes | 0, No | 99, Unknown

This refers to whether the patient was symptomatic at the initial presentation.

Indicate ‘Yes’, if the patient was symptomatic at the initial presentation.

1

1

presentation

ONSET & PRESENTATION

pres_firstsym

multi_list

Symptom(s) during first 24 hours of illness (select all that apply)

conditions_Symptoms

This refers to the first symptom, or symptoms (if multiple occurred at the same time), that you clinically believe was related to this episode of illness.

Select all symptoms which the patient experienced during the first 24 hours of illness (select all that apply).

1

1

1

1

presentation

ONSET & PRESENTATION

pres_consultdate

date_dmy

Date of first clinical consultation

date_dmy

today

This refers to the date of first clinical consultation related to the current episode of illness.

Enter the date of first clinical consultation related to the current episode of illness. (Use the format DD/MM/YYYY)

1

1

1

1

presentation

ONSET & PRESENTATION

pres_date

date_dmy

Most recent presentation/admission date at this facility

date_dmy

today

This refers to the date of hospitalisation / admission of the patient to your site for the current illness.

Enter the date of hospitalisation / admission to your site. (Use the format DD/MM/YYYY)

SNOMED

32485007, Hospital admission (procedure)

1

1

1

1

1

1

1

1

1

presentation

ONSET & PRESENTATION

pres_adm

radio

Admitted to hospital

1, Yes | 0, No | 99, Unknown

This refers to admission of the patient to your site for the current illness.

Indicate ‘Yes’, if that patient was admitted to your site.

SNOMED

32485007, Presentation to hospital (event)

1

1

1

1

1

1

1

1

presentation

ONSET & PRESENTATION

pres_adm_reas

radio

Reason for hospitalisation

1, Infection of interest | 88, Other

[pres_adm] = ‘1’

This refers to the reason (indication) for hospitalisation.

If ‘Yes’, specify the reason (indication) for hospitalisation.

1

1

1

1

presentation

ONSET & PRESENTATION

pres_adm_reasoth

text

Specify other reason

[pres_adm_reas]=’88’

1

1

presentation

ONSET & PRESENTATION

pres_adm_time

time

Time of hospital admission

time

[pres_adm] = ‘1’

This refers to admission of the patient to your site for the current illness.

Enter the time of admission to your site. (Use 24-hour format (00:00 - 24:00 hours))

1

presentation

ONSET & PRESENTATION

pres_enrolmentdate

date_dmy

Date of enrolment / start of data collection

date_dmy

today

This refers to the date of enrolment / start of data collection.

Enter date of patient study enrolment. (Use the format DD/MM/YYYY)

1

1

1

1

1

1

1

1

presentation

RE-ADMISSION AND PREVIOUS PIN

readm_prev

radio

Was the patient admitted previously or transferred from any other facility during this illness episode?

1, YES-admitted previously to this facility and discharged | 2, YES-admitted to other facility and discharged | 3, YES-admitted to another facility, then transferred to this facility | 0, No | 99, Unknown

This refers to previous admission to a health facility or transfer from another health facility during the current episode of illness.

Select the most appropriate option that represents whether or not the patient admitted previously or transferred from any other facility during this illness episode.

1

presentation

RE-ADMISSION AND PREVIOUS PIN

readm_prev_site

text

Name of transfer facility

[readm_prev] = ‘1’ or [readm_prev]=’2’ or [readm_prev]=’3’

This refers to the name of the facility from which the patient was previously admitted or transferred.

Enter the name of the facility from which the patient was previously admitted or transferred.

1

presentation

RE-ADMISSION AND PREVIOUS PIN

readm_prev_date

date_dmy

Date of presentation at previous facility

date_dmy

today

[readm_prev] = ‘1’ or [readm_prev]=’2’ or [readm_prev]=’3’

This refers to the date of presentation to the facility at which the patient was previously admitted or transferred.

Enter the date of presentation to the facility at which the patient was previously admitted or transferred. (Use the format DD/MM/YYYY)

1

presentation

RE-ADMISSION AND PREVIOUS PIN

readm_prev_num

number

Total number of previous admissions for this infection

number

1

50

[readm_prev] = ‘1’ or [readm_prev]=’2’ or [readm_prev]=’3’

This refers to the number of times (for this infection) the patient has been admitted to a health facility.

Indicate the number of times (for this infection) the patient has been admitted to a health facility.

1

presentation

RE-ADMISSION AND PREVIOUS PIN

readm_firstadmdate

date_dmy

Date of earliest admission for this infection

date_dmy

today

[readm_prev] = ‘1’ or [readm_prev]=’2’ or [readm_prev]=’3’

This refers to the date of the first admission for this illness. If the patient was first ‘admitted to other facility, then transferred to this facility’ record the date the patient was admitted to the other health facility.

Enter the date of the first admission for this illness. (Use the format DD/MM/YYYY)

1

presentation

RE-ADMISSION AND PREVIOUS PIN

readm_difpin

radio

Has the patient’s data been previously collected under a different participant identification number (PIN)?

1, Yes | 0, No | 99, Unknown

This refers to previous collection of the patient’s data under a different Participant Identification Number (PIN)

Indicate ‘Yes’ if the patient’s data has been previously collected under a different participant identification number (PIN)

presentation

RE-ADMISSION AND PREVIOUS PIN

readm_prevpin

text

Previous Participant Identification Number (PIN)

[readm_difpin] = ‘1’

The Participant Identification Number or PIN is a unique number used to identify the patient’s (participant’s) data.

Write the Participant Identification Number (PIN).

presentation

RE-ADMISSION AND PREVIOUS PIN

readm_reas

radio

Is the patient being re-admitted with or due to infection with pathogen of interest?

1, Yes | 0, No | 99, Unknown

This refers to re-admission of the patient with or due to infection with pathogen of interest.

Indicate ‘Yes’ if the patient is being re-admitted with or due to infection with pathogen of interest.

1

presentation

DEMOGRAPHICS

demog_birthknow

radio

Is the date of birth known?

1, Yes | 0, No

This refers to the calendar date on which the patient was born.

Record the participants date of birth in DD/MM/YYYY format.

SNOMED

184099003, Date of birth (observable entity)

C0421451, Patient date of birth

1

1

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1

1

1

1

1

1

1

presentation

DEMOGRAPHICS

demog_birthdate

date_dmy

Date of birth

date_dmy

today

[demog_birthknow]=’1’

This refers to the calendar date on which the patient was born.

Enter the participant’s date of birth. (Use the format DD/MM/YYYY)

SNOMED

184099003, Date of birth (observable entity)

C0421451, Patient date of birth

1

risk_factor_demo

1

1

1

1

1

1

1

1

1

1

presentation

DEMOGRAPHICS

demog_age

number

Age

number

0

150

[demog_birthknow]=’0’

This refers to the patient’s age.

For participants over the age of two years, please report age in years. For children under the age of two years, please report in months. For neonates below the age of one month, please report in days.

SNOMED

424144002, Current chronological age (observable entity)

risk_factor_demo

1

1

1

1

1

1

1

1

1

1

presentation

DEMOGRAPHICS

demog_age_units

radio

Age units

1, Years | 2, Months | 3, Days

[demog_birthknow]=’0’

This refers to the patient’s age at presentation to the health facility.

Select the most appropriate units for age.

SNOMED

424144002, Current chronological age (observable entity)

risk_factor_demo

1

1

1

1

1

1

1

1

1

1

presentation

DEMOGRAPHICS

demog_calcage_days

calc

Calculated Age (days)

if([demog_birthknow]=’1’,datediff([demog_birthdate],[pres_date],”d”),if([demog_age_units]=’1’,[demog_age]*365,if([demog_age_units]=’2’,round([demog_age]*365/12,0),if([demog_age_units]=’3’,[demog_age],’’))))

This refers to the patient’s age in days.

Age is calculated, if the date of birth is known, as the difference between the date of birth and the most recent date of presentation or admission to the facility.

SNOMED

424144002, Current chronological age (observable entity)

risk_factor_demo

1

1

1

1

1

1

1

1

1

presentation

DEMOGRAPHICS

demog_sex

radio

Sex at birth

1, Male | 2, Female | 99, Not specified/Unknown | 88, Other

This refers to the physical sexual characteristics at birth.

Select the most appropriate option that represents the physical sexual characteristics at birth.

SNOMED

281053000, Sex of baby at delivery (observable entity)

risk_factor_demo

1

1

1

1

1

1

1

1

1

presentation

DEMOGRAPHICS

demog_sex_oth

text

Specify other sex at birth

[demog_sex]=’88’

This refers to the physical sexual characteristics at birth.

If ‘Other’, specify the physical sexual characteristics at birth.

SNOMED

281053000, Sex of baby at delivery (observable entity)

risk_factor_demo

1

1

1

1

1

1

1

presentation

DEMOGRAPHICS

demog_gender

radio

Gender

1, Male | 2, Female | 3, Non-binary | 99, Unknown | 88, Other

[demog_calcage_days]>3650

This refers to a person’s internally held sense of their gender, which may or may not correspond to the individual’s genotypic or phenotypic sex.

Select the most appropriate option that represents the patient’s gender identity.

SNOMED

263495000, Gender (observable entity)

C0079399, Gender

1

1

1

1

1

1

1

presentation

DEMOGRAPHICS

demog_gender_oth

text

Specify other gender

[demog_gender]=’88’

This refers to a person’s internally held sense of their gender, which may or may not correspond to the individual’s genotypic or phenotypic sex.

If ‘Other’ specify patient’s gender identity.

SNOMED

263495000, Gender (observable entity)

C0079399, Gender

1

1

1

1

1

1

1

presentation

DEMOGRAPHICS

demog_country

user_list

Country

demographics_Country

This refers to the country of enrolment

Indicate the country of enrolment

presentation

DEMOGRAPHICS

demog_outcountry

radio

Was the patient born outside the reporting country?

1, Yes | 0, No | 99, Unknown

This refers to birth of the particpant outside the reporting country

Indicate whether the particpant was born outside the reporting country

presentation

DEMOGRAPHICS

demog_height

number

Height

number

0

250

Actual or closest estimate to height at time of admission.

This refers to the distance from the sole to the crown of the head with body standing on a flat surface and fully extended. For children under the age of 2, please use body length (measured while lying supine).

1

1

1

1

1

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1

presentation

DEMOGRAPHICS

demog_height_units

radio

Height (select units)

1, cm | 2, in

units

1

1

1

1

1

1

presentation

DEMOGRAPHICS

demog_height_cm

number

Height (cm)

number

0

250

Actual or closest estimate to height at time of admission.

This refers to the distance from the sole to the crown of the head with body standing on a flat surface and fully extended, measured in centimetres (cm). For children under the age of 2, please use body length (measured while lying supine).

SNOMED

1153637007, Body height (observable entity)

C0489786, Height

1

1

1

1

1

presentation

DEMOGRAPHICS

demog_height_in

number

Height (in)

number

0

98

Actual or closest estimate to height at time of admission.

This refers to the distance from the sole to the crown of the head with body standing on a flat surface and fully extended, measured in inches (in). For children under the age of 2, please use body length (measured while lying supine).

1153637007, Body height (observable entity)

C0489786, Height

1

1

1

1

1

presentation

DEMOGRAPHICS

demog_weight

number

Weight

number

0

1763

Actual or closest estimate to weight at time of admission.

Indicate the patient’s weight.

1

1

1

1

1

1

1

1

presentation

DEMOGRAPHICS

demog_weight_units

radio

Weight (select units)

1, kg | 2, lb

units

1

1

1

1

1

1

1

presentation

DEMOGRAPHICS

demog_weight_kg

number

Weight (kg)

number

0

800

Actual or closest estimate to weight at time of admission.

Indicate the patient’s weight in kilograms (kg).

SNOMED

27113001, Body weight (observable entity)

C0005910, Body Weight

1

1

1

1

1

1

presentation

DEMOGRAPHICS

demog_weight_lb

number

Weight (lb)

number

0

1763

Actual or closest estimate to weight at time of admission.

Indicate the patient’s weight in pounds (lb).

27113001, Body weight (observable entity)

C0005910, Body Weight

1

1

1

1

1

1

presentation

DEMOGRAPHICS

demog_race

multi_list

Race (select all that apply)

demographics_Race

This refers to a geographic ancestral origin category that is assigned to a population group based mainly on physical characteristics that are thought to be distinct and inherent.

Select all that apply.

SNOMED

103579009, Race (observable entity)

C3853635, Race

1

presentation

DEMOGRAPHICS

demog_healthcare

radio

Employed as a healthcare worker

1, Yes | 0, No | 99, Unknown

[demog_calcage_days]>5840

This refers to a patient that is employed in the healthcare industry.

Select the most appropriate option.

SNOMED

223366009, Healthcare professional (occupation)

risk_factor_socio

1

1

1

1

1

presentation

DEMOGRAPHICS

demog_healthcare_ptfacing

radio

Patient facing

1, Yes | 0, No | 99, Unknown

[demog_healthcare] = ‘1’

This refers to a patient that is employed in the healthcare industry delivering care in patient-facing settings (i.e. roles that involve interaction directly with patients).

Select the most appropriate option.

SNOMED

223366009, Healthcare professional (occupation)

risk_factor_socio

1

1

1

1

1

presentation

DEMOGRAPHICS

demog_healthcare_expbiosample

radio

Exposed to biological samples

1, Yes | 0, No | 99, Unknown

[demog_healthcare] = ‘1’

This refers to a patient that is employed in the healthcare industry delivering care in non-patient facing settings but are exposed to biological samples (e.g. laboratory staff, medical waste handlers).

Select the most appropriate option.

SNOMED

223366009, Healthcare professional (occupation)

risk_factor_socio

1

1

1

1

1

presentation

DEMOGRAPHICS

demog_riskoccupa

user_list

Does the patient practise any of these professions or a profession related to their infection

demographics_Occupation

This refers to the principal activity that a person does to earn a living.

Select all that apply.

risk_factor_socio

1

1

presentation

DEMOGRAPHICS

demog_occupation

radio

Primary location of occupation

1, Home-working or unemployed | 2, Indoors-office/health/education/hospitality/business/homes | 3, Indoors-factory | 8, Outdoors-animal contact (vet, animal farmer, abattoir worker) | 4, Outdoors-agriculture/forestry/fisheries | 5, Outdoors-construction/industrial/mining | 6, Armed Forces | 7, Student | 99, Unknown | 88, Other

This refers to the location in which the patient conducts the majority of work related to their current occupation.

Select the most appropriate option that represents the primary location of occupation.

risk_factor_socio

1

1

1

presentation

DEMOGRAPHICS

demog_occupation_oth

text

Specify other primary location of occupation

[demog_occupation]=’88’

This refers to the location in which the patient conducts the majority of work related to their current occupation.

If ‘Other’, specify the primary location of occupation.

risk_factor_socio

1

1

1

presentation

DEMOGRAPHICS

demog_residence

radio

Patient’s city of residence

1, Same as health care facility | 2, Different from health care facility | 99, Unknown

This refers to the city which a person dwells more than temporarily or lives permanently.

If the patient’s city of residence is different to the city in which this healthcare facility is located, Specify the patient’s region of residence below.

SNOMED

433178008, City of residence (observable entity)

C2316883, City of residence

risk_factor_socio

1

1

1

presentation

DEMOGRAPHICS

demog_residence_oth

text

If different from health case facility, specify the patient’s region of residence.

[demog_residence]=’2’

This refers to the city which a person dwells more than temporarily or lives permanently.

If ‘Different from health case facility’, specify the patient’s region of residence.

SNOMED

433178008, City of residence (observable entity)

C2316883, City of residence

risk_factor_socio

1

1

presentation

EXPOSURE HISTORY IN PREVIOUS 14 DAYS

expo14_travel

radio

Did the patient travel outside of their home region in the past 14 days?

1, Yes | 0, No | 99, Unknown

This refers to travel to another city/town or region, another part of the country or abroad to another country within 14 days before symptoms relating to the current illness began.

Indicate ‘Yes’, if the patient travelled to another city/town or region, another part of the country or abroad to another country within 14 days before symptoms relating to the current illness began.

SNOMED

129018004, Traveling (observable entity)

C0040802, travel

1

1

1

1

presentation

EXPOSURE HISTORY IN PREVIOUS 14 DAYS

expo14_travel_loc

notes

specify all city / cities or town(s) and region(s) of travel

[expo14_travel] = ‘1’

This refers to all city / cities or town(s) and region(s), which the patient travelled to within 14 days before symptoms relating to the current illness began.

If the patient has travelled away from their usual place of residence within 14 days of symptom onset, enter the location(s) that were visited.

1

1

1

presentation

EXPOSURE HISTORY IN PREVIOUS 14 DAYS

expo14_yn

radio

History of contact with suspected or confirmed human case of same pathogen?

1, Yes | 0, No | 99, Unknown

This refers to the patient having a history of contact with anyone presenting with similar symptoms or with known confirmed case, or with contaminated material from a suspected or confirmed case (e.g. body fluids, objects, bedding etc.).

Indicate ‘Yes’, if the patient has a history of contact with anyone presenting with similar symptoms or with known confirmed case, or with contaminated material from a suspected or confirmed case (e.g. body fluids, objects, bedding etc.).

1

1

1

1

1

1

1

presentation

EXPOSURE HISTORY IN PREVIOUS 14 DAYS

expo14_typecomm

radio

Community contact

1, Yes | 0, No | 99, Unknown

[expo14_yn]=’1’

This refers to the mode of exposure to a suspected or confirmed case. Community contact refers to exposure event outside of healthcare setting.

Indicate ‘Yes’ if the patient experienced this mode of exposure to a suspected or confirmed human case.

SNOMED

277057000, Community acquired (qualifier value) | 1290740005, Vertical transmission (qualifier value) | 8098009, Sexually transmitted infectious disease (disorder)

C5392207, Community Transmission | C0242648, Vertical Disease Transmission | C0036916, Sexually Transmitted Diseases

1

1

presentation

EXPOSURE HISTORY IN PREVIOUS 14 DAYS

expo14_typevert

radio

Vertical transmission

1, Yes | 0, No | 99, Unknown

[expo14_yn]=’1’ and [demog_calcage_days]<365

This refers to the mode of exposure to a suspected or confirmed case. Vertical transmission refers to transmission from mother-to-child.

Indicate ‘Yes’ if the patient experienced this mode of exposure to a suspected or confirmed human case.

SNOMED

277057000, Community acquired (qualifier value) | 1290740005, Vertical transmission (qualifier value) | 8098009, Sexually transmitted infectious disease (disorder)

C5392207, Community Transmission | C0242648, Vertical Disease Transmission | C0036916, Sexually Transmitted Diseases

1

1

1

presentation

EXPOSURE HISTORY IN PREVIOUS 14 DAYS

expo14_typehcw

radio

Healthcare worker exposure

1, Yes | 0, No | 99, Unknown

[expo14_yn]=’1’ and [demog_calcage_days]>5840

This refers to the mode of exposure to a suspected or confirmed case. Healthcare worker exposure refers to an exposure event in a healthcare setting.

Indicate ‘Yes’ if the patient experienced this mode of exposure to a suspected or confirmed human case.

SNOMED

277057000, Community acquired (qualifier value) | 1290740005, Vertical transmission (qualifier value) | 8098009, Sexually transmitted infectious disease (disorder)

C5392207, Community Transmission | C0242648, Vertical Disease Transmission | C0036916, Sexually Transmitted Diseases

1

1

presentation

EXPOSURE HISTORY IN PREVIOUS 14 DAYS

expo14_typesext

radio

Sexual transmission

1, Yes | 0, No | 99, Unknown

[expo14_yn]=’1’ and [demog_calcage_days]>5840

This refers to the mode of exposure to a suspected or confirmed case. Sexual transmission refers to infection propagated by sexual contact.

Indicate ‘Yes’ if the patient experienced this mode of exposure to a suspected or confirmed human case.

SNOMED

277057000, Community acquired (qualifier value) | 1290740005, Vertical transmission (qualifier value) | 8098009, Sexually transmitted infectious disease (disorder)

C5392207, Community Transmission | C0242648, Vertical Disease Transmission | C0036916, Sexually Transmitted Diseases

1

1

presentation

EXPOSURE HISTORY IN PREVIOUS 14 DAYS

expo14_typefaml

radio

Family / household contacts

1, Yes | 0, No | 99, Unknown

[expo14_yn]=’1’

This refers to the mode of exposure to a suspected or confirmed case. Family / household contact refers to infection transmission from individuals who expect to share living accommodation on most days (and therefore for whom continuing close contact is unavoidable)

Indicate ‘Yes’ if the patient experienced this mode of exposure to a suspected or confirmed human case.

SNOMED

277057000, Community acquired (qualifier value) | 1290740005, Vertical transmission (qualifier value) | 8098009, Sexually transmitted infectious disease (disorder)

C5392207, Community Transmission | C0242648, Vertical Disease Transmission | C0036916, Sexually Transmitted Diseases

1

1

1

presentation

EXPOSURE HISTORY IN PREVIOUS 14 DAYS

expo14_typeschool

radio

Childcare settings/school exposures

1, Yes | 0, No | 99, Unknown

[expo14_yn]=’1’

This refers to the mode of exposure to a suspected or confirmed case occuring within childcare settings or school-related exposures.

Indicate ‘Yes’ if the patient experienced this mode of exposure to a suspected or confirmed human case.

1

presentation

EXPOSURE HISTORY IN PREVIOUS 14 DAYS

expo14_typeoth

radio

Other type of human exposure

1, Yes | 0, No | 99, Unknown

[expo14_yn]=’1’

This refers to other mode(s) of exposure to a suspected or confirmed case not specified above.

Indicate ‘Yes’ if the patient experienced this mode of exposure to a suspected or confirmed human case.

SNOMED

277057000, Community acquired (qualifier value) | 1290740005, Vertical transmission (qualifier value) | 8098009, Sexually transmitted infectious disease (disorder)

C5392207, Community Transmission | C0242648, Vertical Disease Transmission | C0036916, Sexually Transmitted Diseases

1

1

presentation

EXPOSURE HISTORY IN PREVIOUS 14 DAYS

expo14_typeoth_spec

text

Specify other type of human exposure

[expo14_typeoth]=’1’

This refers to other mode(s) of exposure to a suspected or confirmed case not specified above.

If ‘Other’, specify the mode of exposure to a suspected or confirmed case.

1

1

presentation

EXPOSURE HISTORY IN PREVIOUS 14 DAYS

expo14_date

date_dmy

Date of contact with suspected or confirmed case

date_dmy

today

[expo14_yn]=’1’

This refers to the date of contact with anyone presenting with similar symptoms or with known confirmed case, or with contaminated material from a suspected or confirmed case (e.g. body fluids, objects, bedding etc.).

Enter the date of contact with suspected or confirmed human case. (Use the format DD/MM/YYYY)

1

1

1

1

presentation

EXPOSURE HISTORY IN PREVIOUS 14 DAYS

expo14_setting

radio

Contact setting

1, Household | 2, Occupational | 4, Healthcare facility | 99, Unknown | 88, Other

This refers to the environment within which the person may have come into contact with a suspected or confirmed case.

Select the most appropriate option that represents the contact setting with a confirmed or suspected human case.

1

1

presentation

EXPOSURE HISTORY IN PREVIOUS 14 DAYS

expo14_setting_oth

text

Specify other contact setting

[expo14_setting]=’88’

This refers to the environment within which the person may have come into contact with a suspected or confirmed case.

If ‘Other’, specify the contact setting with a confirmed or suspected case.

1

1

presentation

EXPOSURE HISTORY IN PREVIOUS 14 DAYS

expo14_ancon

radio

Any contact with animals, animal homes, meats or other animal products in the last 14 days?

1, Yes | 0, No | 99, Unknown

This refers to contact with animals, animal homes, meats or other animal products which occurred in the last 14 days.

Indicate ‘Yes’ if the patient was in contact with animals, animal homes, meats or other animal products which occurred in the last 14 days.

1

1

1

1

presentation

EXPOSURE HISTORY IN PREVIOUS 14 DAYS

expo14_ancon_date

date_dmy

Date of contact with suspected or confirmed animal source

date_dmy

today

[expo14_ancon]=’1’

This refers to the date of contact with animals, animal homes, meats or other animal products which occurred in the last 14 days.

Enter the date of contact with animals, animal homes, meats or other animal products which occurred in the last 14 days. (Use the format DD/MM/YYYY)

1

1

1

presentation

EXPOSURE HISTORY IN PREVIOUS 14 DAYS

expo14_ancon_lstock

radio

Contact with livestock

1, Yes | 0, No | 99, Unknown

[expo14_ancon]=’1’

This refers to contact with live bird (e.g. chickens, turkeys, ducks) which occurred in the last 14 days.

Indicate ‘Yes’ if the patient experienced this in the last 14 days.

1

1

1

presentation

EXPOSURE HISTORY IN PREVIOUS 14 DAYS

expo14_ancon_lstock_type

checkbox

Livestock type

1, Poultry/birds | 2, Dairy cows/equipment | 3, Other cattle | 4, Pigs

[expo14_ancon_lstock] = ‘1’

This refers to contact with live bird (e.g. chickens, turkeys, ducks) which occurred in the last 14 days.

Indicate ‘Yes’ if the patient experienced this in the last 14 days.

1

1

presentation

EXPOSURE HISTORY IN PREVIOUS 14 DAYS

expo14_ancon_lstock_cttype

checkbox

Specify type of contact

1, Hunting | 2, Preparing | 3, Handling | 4, Consumption (unprocessed / undercooked / raw) | 5, Trading | 6, Animal faeces or nests | 7, Sick or dead animal | 99, Unknown | 88, Other

[expo14_ancon_lstock] = ‘1’

This refers to the type(s) of animal contact which occurred in the last 14 days. Hunting includes findings or killing animal(s) for food or sport. Preparing incudes skinning, dressing or butchering animal(s) for consumption. Handling includes touching, petting or sharing living area with animal(s). Consumption includes ingesting unprocessed, undercooked or raw animal part(s). Trading includes animal contact from selling, buying or exchanging animal(s). Animal faeces or nests includes contact with faeces, nests or homes of animal(s). Sick or dead animals refers to contact with a sick or dead animal but not participation in animal surgery or nercopsy (seperate question).

Select all the type(s) of animal contact which occurred in the last 14 days.

1

1

presentation

EXPOSURE HISTORY IN PREVIOUS 14 DAYS

expo14_ancon_nhprim

radio

Contact with non-human primates

1, Yes | 0, No | 99, Unknown

[expo14_ancon]=’1’

This refers to contact with non-human primates (a group of mammals composed of simians monkeys and apes and prosimians, such as lemurs) which occurred in the last 14 days.

Indicate ‘Yes’ if the patient experienced this in the last 14 days.

1

1

presentation

EXPOSURE HISTORY IN PREVIOUS 14 DAYS

expo14_ancon_nhprim_type

checkbox

Non-human primates type

1, Monkeys | 2, Apes

[expo14_ancon_nhprim]=’1’

This refers to contact with monkeys which occurred in the last 14 days.

Indicate ‘Yes’ if the patient experienced this in the last 14 days.

1

1

presentation

EXPOSURE HISTORY IN PREVIOUS 14 DAYS

expo14_ancon_nhprim_cttype

checkbox

Specify type of contact

1, Hunting | 2, Preparing | 3, Handling | 4, Consumption (unprocessed / undercooked / raw) | 5, Trading | 6, Animal faeces or nests | 7, Sick or dead animal | 99, Unknown | 88, Other

[expo14_ancon_nhprim]=’1’

This refers to the type(s) of animal contact which occurred in the last 14 days. Hunting includes findings or killing animal(s) for food or sport. Preparing incudes skinning, dressing or butchering animal(s) for consumption. Handling includes touching, petting or sharing living area with animal(s). Consumption includes ingesting unprocessed, undercooked or raw animal part(s). Trading includes animal contact from selling, buying or exchanging animal(s). Animal faeces or nests includes contact with faeces, nests or homes of animal(s). Sick or dead animals refers to contact with a sick or dead animal but not participation in animal surgery or nercopsy (seperate question).

Select all the type(s) of animal contact which occurred in the last 14 days.

1

1

presentation

EXPOSURE HISTORY IN PREVIOUS 14 DAYS

expo14_ancon_rodent

radio

Contact with rodents

1, Yes | 0, No | 99, Unknown

[expo14_ancon]=’1’

This refers to contact with rodents (e.g. rats, mice, squirrels) which occurred in the last 14 days.

Indicate ‘Yes’ if the patient experienced this in the last 14 days.

1

1

presentation

EXPOSURE HISTORY IN PREVIOUS 14 DAYS

expo14_ancon_rodent_type

checkbox

Rodents type

1, Rats | 2, Mice | 3, Squirrels

[expo14_ancon_rodent] = ‘1’

This refers to contact with rats which occurred in the last 14 days.

Indicate ‘Yes’ if the patient experienced this in the last 14 days.

1

1

presentation

EXPOSURE HISTORY IN PREVIOUS 14 DAYS

expo14_ancon_rodent_cttype

checkbox

Specify type of contact

1, Hunting | 2, Preparing | 3, Handling | 4, Consumption (unprocessed / undercooked / raw) | 5, Trading | 6, Animal faeces or nests | 7, Sick or dead animal | 99, Unknown | 88, Other

[expo14_ancon_rodent] = ‘1’

This refers to the type(s) of animal contact which occurred in the last 14 days. Hunting includes findings or killing animal(s) for food or sport. Preparing incudes skinning, dressing or butchering animal(s) for consumption. Handling includes touching, petting or sharing living area with animal(s). Consumption includes ingesting unprocessed, undercooked or raw animal part(s). Trading includes animal contact from selling, buying or exchanging animal(s). Animal faeces or nests includes contact with faeces, nests or homes of animal(s). Sick or dead animals refers to contact with a sick or dead animal but not participation in animal surgery or nercopsy (seperate question).

Select all the type(s) of animal contact which occurred in the last 14 days.

1

1

presentation

EXPOSURE HISTORY IN PREVIOUS 14 DAYS

expo14_ancon_pets

radio

Contact with pets

1, Yes | 0, No | 99, Unknown

[expo14_ancon]=’1’

This refers to contact with household pets (excluding rodents) which occurred in the last 14 days.

Indicate ‘Yes’ if the patient experienced this in the last 14 days.

1

1

presentation

EXPOSURE HISTORY IN PREVIOUS 14 DAYS

expo14_ancon_pets_type

checkbox

Pets type

1, Cats | 2, Dogs

[expo14_ancon_pets]=’1’

This refers to contact with cats which occurred in the last 14 days.

Indicate ‘Yes’ if the patient experienced this in the last 14 days.

1

1

presentation

EXPOSURE HISTORY IN PREVIOUS 14 DAYS

expo14_ancon_pets_cttype

checkbox

Specify type of contact

1, Hunting | 2, Preparing | 3, Handling | 4, Consumption (unprocessed / undercooked / raw) | 5, Trading | 6, Animal faeces or nests | 7, Sick or dead animal | 99, Unknown | 88, Other

[expo14_ancon_pets]=’1’

This refers to the type(s) of animal contact which occurred in the last 14 days. Hunting includes findings or killing animal(s) for food or sport. Preparing incudes skinning, dressing or butchering animal(s) for consumption. Handling includes touching, petting or sharing living area with animal(s). Consumption includes ingesting unprocessed, undercooked or raw animal part(s). Trading includes animal contact from selling, buying or exchanging animal(s). Animal faeces or nests includes contact with faeces, nests or homes of animal(s). Sick or dead animals refers to contact with a sick or dead animal but not participation in animal surgery or nercopsy (seperate question).

Select all the type(s) of animal contact which occurred in the last 14 days.

1

1

presentation

EXPOSURE HISTORY IN PREVIOUS 14 DAYS

expo14_ancon_wildlife

radio

Contact with wildlife

1, Yes | 0, No | 99, Unknown

[expo14_ancon]=’1’

This refers to contact with animals considered to be wild or feral or not adapted for domestic use which occurred in the last 14 days.

Indicate ‘Yes’ if the patient experienced this in the last 14 days.

1

1

1

presentation

EXPOSURE HISTORY IN PREVIOUS 14 DAYS

expo14_ancon_wildelife_type

checkbox

Wildlife type

1, Bats |88, Other

[expo14_ancon_wildlife]=’1’

This refers to contact with bats which occurred in the last 14 days.

Indicate ‘Yes’ if the patient experienced this in the last 14 days.

1

presentation

EXPOSURE HISTORY IN PREVIOUS 14 DAYS

expo14_ancon_wildelife_oth

text

Specify other wildlife type

[expo14_ancon_wildelife_type(88)]=’1’

presentation

EXPOSURE HISTORY IN PREVIOUS 14 DAYS

expo14_ancon_wildlife_cttype

checkbox

Specify type of contact

1, Hunting | 2, Preparing | 3, Handling | 4, Consumption (unprocessed / undercooked / raw) | 5, Trading | 6, Animal faeces or nests | 7, Sick or dead animal | 99, Unknown | 88, Other

[expo14_ancon_wildlife]=’1’

This refers to the type(s) of animal contact which occurred in the last 14 days. Hunting includes findings or killing animal(s) for food or sport. Preparing incudes skinning, dressing or butchering animal(s) for consumption. Handling includes touching, petting or sharing living area with animal(s). Consumption includes ingesting unprocessed, undercooked or raw animal part(s). Trading includes animal contact from selling, buying or exchanging animal(s). Animal faeces or nests includes contact with faeces, nests or homes of animal(s). Sick or dead animals refers to contact with a sick or dead animal but not participation in animal surgery or nercopsy (seperate question).

Select all the type(s) of animal contact which occurred in the last 14 days.

1

1

1

presentation

EXPOSURE HISTORY IN PREVIOUS 14 DAYS

expo14_ancon_unpasteur

radio

Contact with or consumption of unpasteurised milk or raw dairy products

1, Yes | 0, No | 99, Unknown

[expo14_ancon]=’1’

This refers to contact with or consumption of unpasteurised milk or dairy products which occurred in the last 14 days.

Indicate ‘Yes’ if the patient experienced this in the last 14 days.

1

1

1

presentation

EXPOSURE HISTORY IN PREVIOUS 14 DAYS

expo14_ancon_visitzoo

radio

Visit to live animal market, farm or zoo

1, Yes | 0, No | 99, Unknown

[expo14_ancon]=’1’

This refers to visit to live animal market, farm or zoo which occurred in the last 14 days.

Indicate ‘Yes’ if the patient experienced this in the last 14 days.

1

1

presentation

EXPOSURE HISTORY IN PREVIOUS 14 DAYS

expo14_ancon_animalsurg

radio

Participated in animal surgery or necropsy

1, Yes | 0, No | 99, Unknown

[expo14_ancon]=’1’

This refers to participation in animal surgery or necropsy which occurred in the last 14 days.

Indicate ‘Yes’ if the patient experienced this in the last 14 days.

1

1

presentation

EXPOSURE HISTORY IN PREVIOUS 14 DAYS

expo14_ancon_bite

radio

Any insect or arthropod bites (eg. mosquitoes, ticks)

1, Yes | 0, No | 99, Unknown

[expo14_ancon]=’1’

1

presentation

EXPOSURE HISTORY IN PREVIOUS 14 DAYS

expo14_ancon_other

radio

Other animal contact not listed above

1, Yes | 0, No | 99, Unknown

[expo14_ancon]=’1’

This refers to other animal contact, not listed above, which occurred in the last 14 days.

Indicate ‘Yes’ if the patient experienced this in the last 14 days.

1

1

1

1

presentation

EXPOSURE HISTORY IN PREVIOUS 14 DAYS

expo14_ancon_other_spec

text

Specify animal contacts not listed above

[expo14_ancon_other]=’1’

This refers to other animal contact, not listed above, which occurred in the last 14 days.

If ‘Yes’, specify any other animal contact with occurred in the last 14 days.

1

1

1

1

presentation

EXPOSURE HISTORY IN PREVIOUS 14 DAYS

expo14_ancon_other_cttype

checkbox

Specify type of contact

1, Hunting | 2, Preparing | 3, Handling | 4, Consumption (unprocessed / undercooked / raw) | 5, Trading | 6, Animal faeces or nests | 7, Sick or dead animal | 99, Unknown | 88, Other

[expo14_ancon_other]=’1’

This refers to the type(s) of animal contact which occurred in the last 14 days. Hunting includes findings or killing animal(s) for food or sport. Preparing incudes skinning, dressing or butchering animal(s) for consumption. Handling includes touching, petting or sharing living area with animal(s). Consumption includes ingesting unprocessed, undercooked or raw animal part(s). Trading includes animal contact from selling, buying or exchanging animal(s). Animal faeces or nests includes contact with faeces, nests or homes of animal(s). Sick or dead animals refers to contact with a sick or dead animal but not participation in animal surgery or nercopsy (seperate question).

Select all the type(s) of animal contact which occurred in the last 14 days.

1

1

1

1

presentation

EXPOSURE HISTORY IN PREVIOUS 14 DAYS

expo14_house

radio

Any unwell household members in the two weeks prior to the admission of case?

1, Yes | 0, No | 99, Unknown

This refers to any household members of the suspected/confirmed case being unwell in the two weeks prior to the admission of the case.

Indicate ‘Yes’ if any household members of the suspected/confirmed case were unwell in the two weeks prior to the admission of the case.

1

presentation

EXPOSURE HISTORY IN PREVIOUS 14 DAYS

expo14_house_sys

checkbox

Which system(s) are affected? (tick all that apply)

1, Respiratory | 2, Gastrointestinal | 3, Cardiovascular | 4, Central Nervous system | 5, Peripheral Nervous system | 6, Mucocutaneous | 7, Ocualar | 99, Unknown | 88, Other

[expo14_house]=’1’

This refers to the body system(s) of the unwell household members which were affected during the illness.

Select all the system(s) which were affected.

1

presentation

EXPOSURE HISTORY IN PREVIOUS 14 DAYS

expo14_house_sys_oth

text

Specify other system(s) affected

[expo14_house_sys(88)]=’1’

This refers to the body system(s) of the unwell household members which were affected during the illness.

If ‘Other’, specify the system(s) which were affected.

1

presentation

EXPOSURE HISTORY IN PREVIOUS 14 DAYS

expo14_housecon

radio

Have household members had any contact with a confirmed case of the same infection?

1, Yes | 0, No | 99, Unknown

This refers to any household member(s) having any form of contact with a confirmed case of the pathogen of interest.

Indicate ‘Yes’ if any household member(s) had any form of contact with a confirmed case of the pathogen of interest.

presentation

EXPOSURE HISTORY IN PREVIOUS 14 DAYS

expo14_ferm

radio

Consumption of fermented or traditionally locally prepared food/drinks

1, Yes | 0, No | 99, Unknown

1

presentation

EXPOSURE HISTORY IN PREVIOUS 14 DAYS

expo14_swim

radio

Patient swam or bathed in pools, ponds, or rivers

1, Yes | 0, No | 99, Unknown

1

presentation

EXPOSURE HISTORY IN PREVIOUS 14 DAYS

expo14_floodwater

radio

Exposure to flood water/stagnant water bodies or contaminated water

1, Yes | 0, No | 99, Unknown

1

presentation

EXPOSURE HISTORY IN PREVIOUS 14 DAYS

expo14_closeliving

radio

Lives in close quarters

1, Yes | 0, No | 99, Unknown

1

presentation

CO-MORBIDITIES AND RISK FACTORS: Existing prior to this current illness and is ongoing

comor_cns

descriptive

Neurological comorbidities

Nervous system

This refers to comorbidities relating to the nervous system.

risk_factor_comor

1

1

1

1

1

1

1

1

presentation

CO-MORBIDITIES AND RISK FACTORS: Existing prior to this current illness and is ongoing

comor_chrneurolo

radio

Chronic neurological disorder

1, Yes | 0, No | 99, Unknown

Nervous system

Includes disorders of the brain, spinal cord, cranial nerves, peripheral nerves, nerve roots, autonomic nervous system, neuromuscular junction, and muscle. This can include any of cerebral palsy, multiple sclerosis, motor neurone disease, muscular dystrophy, myasthenia gravis, Parkinson’s disease, stroke, and severe learning difficulty.

Indicate ‘Yes’, if this is condition existed prior to admission with this current illness and remains an active medical condition.

SNOMED

118940003, Disorder of the nervous system (disorder)

C0027765, Nervous system disorder

risk_factor_comor

1

1

1

1

1

1

1

1

presentation

CO-MORBIDITIES AND RISK FACTORS: Existing prior to this current illness and is ongoing

comor_epilepsy

radio

Epilepsy

1, Yes | 0, No | 99, Unknown

Nervous system

This refers to a disorder causing recurrent unprovoked seizures

Indicate ‘Yes’, if the patient has experienced this at any time from onset of this illness to presentation.

SNOMED

84757009, Epilepsy (disorder)

risk_factor_comor

1

1

1

presentation

CO-MORBIDITIES AND RISK FACTORS: Existing prior to this current illness and is ongoing

comor_dementia

radio

Dementia

1, Yes | 0, No | 99, Unknown

Nervous system

Defined as evidence from the history and mental status examination that indicates major impairment in learning and memory as well as impairment in at least one of the following: handling complex tasks; reasoning ability; spatial ability and orientation; language. The cognitive symptoms must significantly interfere with the individual’s work performance, usual social activities, or relationships with other people. This must represent a significant decline from a previous level of functioning. The disturbances are not occurring exclusively during the course of delirium, and the disturbances are not better accounted for by a major psychiatric diagnosis. Chronic cognitive deficit is included.

Indicate ‘Yes’, if this is condition existed prior to admission with this current illness and remains an active medical condition.

SNOMED

52448006, Dementia

C1969275, Dementia

risk_factor_comor

1

1

1

1

1

1

1

presentation

CO-MORBIDITIES AND RISK FACTORS: Existing prior to this current illness and is ongoing

comor_strokecva

radio

Stroke / cerebrovascular accident

1, Yes | 0, No | 99, Unknown

Nervous system

Defined as a sudden loss of neurological function secondary to haemorrhage or ischemia in the brain parenchyma due to a vascular event. Stroke may be a clinical diagnosis, with or without supportive radiological findings.

Indicate ‘Yes’, if this is condition existed prior to admission with this current illness and remains an active medical condition.

SNOMED

230690007, Cerebrovascular accident

C3554760, Stroke

risk_factor_comor

1

1

1

presentation

CO-MORBIDITIES AND RISK FACTORS: Existing prior to this current illness and is ongoing

comor_hemipleg

radio

Hemiplegia

1, Yes | 0, No | 99, Unknown

Nervous system

This refers to severe or complete loss of motor function on one side of the body; often caused by brain diseases that are localized to the cerebral hemisphere opposite to the side of weakness; less frequently, brain stem lesions; cervical spinal cord diseases, peripheral nervous system diseases, and other conditions may manifest as hemiplegia.

Indicate ‘Yes’, if this is condition existed prior to admission with this current illness and remains an active medical condition.

SNOMED

50582007, Hemiplegia (disorder)

C0018991, Hemiplegia

risk_factor_comor

1

1

presentation

CO-MORBIDITIES AND RISK FACTORS: Existing prior to this current illness and is ongoing

comor_parapleg

radio

Paraplegia

1, Yes | 0, No | 99, Unknown

Nervous system

This refers to complete paralysis of the lower half of the body including both legs, often caused by damage to the spinal cord.

Indicate ‘Yes’, if this is condition existed prior to admission with this current illness and remains an active medical condition.

SNOMED

60389000, Paraplegia (disorder)

C0030486, Paraplegia

risk_factor_comor

1

1

presentation

CO-MORBIDITIES AND RISK FACTORS: Existing prior to this current illness and is ongoing

comor_cvs

descriptive

Cardiovascular comorbidities

Cardiovascular

This refers to comorbidities relating to the cardiovascular system.

risk_factor_comor

1

1

1

1

1

1

1

1

presentation

CO-MORBIDITIES AND RISK FACTORS: Existing prior to this current illness and is ongoing

comor_chrcardiac

radio

Chronic cardiac disease (not hypertension)

1, Yes | 0, No | 99, Unknown

Cardiovascular

Defined as a disease that progressively causes deterioration of the heart and its functioning. This includes congenital heart diseases (e.g. tetralogy of fallot)

Indicate ‘Yes’, if this is condition existed prior to admission with this current illness and remains an active medical condition.

SNOMED

128238001, Chronic heart disease (disorder)

C1290386, Chronic heart disease

risk_factor_comor

1

1

1

1

1

1

1

1

1

1

presentation

CO-MORBIDITIES AND RISK FACTORS: Existing prior to this current illness and is ongoing

comor_chrcardiac_mi

radio

Myocardial infarction

1, Yes | 0, No | 99, Unknown

[comor_chrcardiac]=’1’

Cardiovascular

Defined as gross necrosis of the myocardium, as a result of interruption of the blood supply to the area, as in coronary thrombosis. This includes previous (history of) myocardial infarction.

Indicate ‘Yes’, if this is condition existed prior to admission with this current illness and remains an active medical condition.

SNOMED

22298006, Myocardial infarction (disorder)

C0027051, Myocardial Infarction

risk_factor_comor

1

1

1

1

presentation

CO-MORBIDITIES AND RISK FACTORS: Existing prior to this current illness and is ongoing

comor_chrcardiac_chf

radio

Congestive heart failure

1, Yes | 0, No | 99, Unknown

[comor_chrcardiac]=’1’

Cardiovascular

Defined as failure of the heart to pump a sufficient amount of blood to meet the needs of the body tissues, resulting in tissue congestion and oedema.

Indicate ‘Yes’, if this is condition existed prior to admission with this current illness and remains an active medical condition.

SNOMED

42343007, Congestive heart failure (disorder)

C0018802, Congestive heart failure

risk_factor_comor

1

1

1

1

presentation

CO-MORBIDITIES AND RISK FACTORS: Existing prior to this current illness and is ongoing

comor_hypertensi

radio

Hypertension

1, Yes | 0, No | 99, Unknown

Cardiovascular

Defined as elevated arterial blood pressure diagnosed clinically (systolic blood pressure >140mmHg systolic and/or diastolic blood pressure >90mmHg), or for which a patient is prescribed an anti-hypertensive.

Indicate ‘Yes’, if this is condition existed prior to admission with this current illness and remains an active medical condition.

SNOMED

38341003, Hypertensive disorder, systemic arterial (disorder)

C0020538, Hypertensive disease

risk_factor_comor

1

1

1

1

1

1

1

1

1

presentation

CO-MORBIDITIES AND RISK FACTORS: Existing prior to this current illness and is ongoing

comor_perivascdis

radio

Peripheral vascular disease

1, Yes | 0, No | 99, Unknown

Cardiovascular

This refers to deviation from or interruption of the normal structure or function of the blood vessels outside the heart; diseases of the peripheral as opposed to the cardiac circulation.

Indicate ‘Yes’, if this is condition existed prior to admission with this current illness and remains an active medical condition.

SNOMED

400047006, Peripheral vascular disease (disorder)

C0085096, Peripheral Vascular Diseases

risk_factor_comor

1

1

presentation

CO-MORBIDITIES AND RISK FACTORS: Existing prior to this current illness and is ongoing

comor_resp

descriptive

Respiratory comorbidities

Respiratory

This refers to comorbidities relating to the respiratory system.

risk_factor_comor

1

1

1

1

1

1

1

1

presentation

CO-MORBIDITIES AND RISK FACTORS: Existing prior to this current illness and is ongoing

comor_chrpulmona

radio

Chronic pulmonary disease (not asthma)

1, Yes | 0, No | 99, Unknown

Respiratory

Defined as any pulmonary condition other than asthma, that is a disease or disorder of slow progression and long duration which causes continuous or episodic periods of illness and/or incapacity.

Indicate ‘Yes’, if this is condition existed prior to admission with this current illness and remains an active medical condition.

SNOMED

413839001, Chronic lung disease

C0746102, Chronic Lung Disorder

risk_factor_comor

1

1

1

1

1

1

1

1

1

1

presentation

CO-MORBIDITIES AND RISK FACTORS: Existing prior to this current illness and is ongoing

comor_asthma

radio

Asthma

1, Yes | 0, No | 99, Unknown

Respiratory

This is defined as clinician-diagnosed asthma, a chronic airway disorder characterized by variable and recurring symptoms of airflow obstruction, bronchial hyper-responsiveness, and/or underlying inflammation. Current pharmaceutical intervention - for prevention or treatment of symptoms - is not a pre-requisite for the inclusion of this diagnosis.

Indicate ‘Yes’, if this is condition existed prior to admission with this current illness and remains an active medical condition.

SNOMED

195967001, Asthma (disorder)

C4229310, Asthma

risk_factor_comor

1

1

1

1

1

1

1

1

1

presentation

CO-MORBIDITIES AND RISK FACTORS: Existing prior to this current illness and is ongoing

comor_git

descriptive

Gastrointestinal comorbidities

Gastrointestinal

This refers to comorbidities relating to the gastrointestinal system.

risk_factor_comor

1

1

1

1

1

1

1

1

presentation

CO-MORBIDITIES AND RISK FACTORS: Existing prior to this current illness and is ongoing

comor_peptulcdis

radio

Peptic ulcer disease

1, Yes | 0, No | 99, Unknown

Gastrointestinal

This refers to acid peptic injury of the digestive tract, resulting in mucosal break reaching the submucosa. Peptic ulcers are usually located in the stomach or proximal duodenum, but they can also be found in the oesophagus or Meckel’s diverticulum.

Indicate ‘Yes’, if this is condition existed prior to admission with this current illness and remains an active medical condition.

SNOMED

13200003, Peptic ulcer (disorder)

C0030920, Peptic ulcer

risk_factor_comor

1

1

presentation

CO-MORBIDITIES AND RISK FACTORS: Existing prior to this current illness and is ongoing

comor_liverdisease

radio

Liver disease

1, Yes | 0, No | 99, Unknown

Gastrointestinal

Defined as any disorder of the hepatobiliary system. Manifestations may include signs and symptoms of cholestasis, portal hypertension, and/or abnormal liver function tests.

Indicate ‘Yes’, if this is condition existed prior to admission and is ongoing.

SNOMED

235856003 | Disorder of liver (disorder)

C0023895, Liver diseases

risk_factor_comor

1

1

1

1

1

1

1

1

1

1

presentation

CO-MORBIDITIES AND RISK FACTORS: Existing prior to this current illness and is ongoing

comor_liverdisease_type

radio

Type of liver disease

1, Mild | 2, Moderate or severe | 99, Unknown

[comor_liverdisease]=’1’

Gastrointestinal

Defined as mild - chronic hepatitis or cirrhosis without portal hypertension, and moderate or severe - cirrhosis with portal hypertension, with or without bleeding or a history of variceal bleeding.

Indicate the type of liver disease. Mild: chronic hepatitis or cirrhosis without portal hypertension. Moderate or severe: cirrhosis with portal hypertension, with or without bleeding or a history of variceal bleeding.

SNOMED

235856003 Disorder of liver (disorder) | 2448400 | 1, Mild (severity modifier) (qualifier value) | 2, 371924009 Moderate to severe (qualifier value)|

C0023895, Liver diseases | C2945599, mild (qualifier value) | C1299393, moderate to severe (qualifier value)

risk_factor_comor

1

1

1

1

1

1

1

1

presentation

CO-MORBIDITIES AND RISK FACTORS: Existing prior to this current illness and is ongoing

comor_renalgut

descriptive

Renal / Genitourinary comorbidities

Renal

This refers to comorbidities relating to the renal / genitourinary system.

Indicate ‘Yes’, if this is condition existed prior to admission with this current illness and remains an active medical condition.

1

1

1

1

1

1

1

1

presentation

CO-MORBIDITIES AND RISK FACTORS: Existing prior to this current illness and is ongoing

comor_chrkidney

radio

Chronic kidney disease

1, Yes | 0, No | 99, Unknown

Renal

This is defined as a clinician-diagnosed chronic kidney disease (CKD, also known as chronic kidney failure). The KDIGO and KDOQI definition of chronic kidney disease is kidney damage for 3 months, as defined by structural or functional abnormalities of the kidney, with or without decreased glomerular filtration rate (GFR), that can lead to decreased GFR, manifest by either: Pathologic abnormalities; or Markers of kidney damage, including abnormalities in the composition of the blood or urine, or abnormalities in imaging tests; or GFR <60 mL/min/1.73 m^2 for 3 months, with or without kidney damage.

Indicate ‘Yes’, if this is condition existed prior to admission with this current illness and remains an active medical condition.

SNOMED

709044004, Chronic kidney disease (disorder)

C1561643

risk_factor_comor

1

1

1

1

1

1

1

1

1

1

presentation

CO-MORBIDITIES AND RISK FACTORS: Existing prior to this current illness and is ongoing

comor_chrkidney_type

radio

Stage of chronic kidney disease

1, Stage 1 | 2, Stage 2 | 3, Stage 3a | 4, Stage 3b | 5, Stage 4 | 6, Stage 5 | 99, Unknown

[comor_chrkidney]=’1’

Renal

This refers to the stage of chronic kidney disease (CKD) based on estimated glomerular filtration rate (eGFR). CKD Stages: 1 - Kidney damage, normal eGFR (90ml/min); 2 - Kidney damage, mild GFR decrease (60-89ml/min); 3a - Moderate GFR decrease (45-59ml/min); 3b - Moderate to severe GFR decrease (30-44ml/min); 4 - Severe GFR decrease (15-29ml/min); 5 - Kidney failure (<15ml/min or on dialysis).

Select the most appropriate option that corresponds to the stage of CKD based on eGFR.

SNOMED

risk_factor_comor

1

1

1

1

1

presentation

CO-MORBIDITIES AND RISK FACTORS: Existing prior to this current illness and is ongoing

comor_inf

descriptive

Infectious comorbidities

Infection

This refers to infection-related comorbidities.

risk_factor_comor

1

1

1

1

1

1

1

1

presentation

CO-MORBIDITIES AND RISK FACTORS: Existing prior to this current illness and is ongoing

comor_aids

radio

HIV

1, Yes | 0, No | 99, Unknown

Infection

Defined as a person living with laboratory-confirmed Human Immunodeficiency Virus (HIV) 1 or 2 infection, or a patient with an Acquired Immunity Deficiency Syndrome (AIDS) defining illness. This is irrespective of the CD4 lymphocyte count/percentage or HIV viral load in blood. ART refers to anti-retroviral therapy and is distinct from pre-exposure prophylaxis (PrEP) or post-exposure prophylaxis (PEP).

Indicate the single most appropriate option that reflects the HIV/AIDS status of the patient and whether they are taking anti-retroviral therapy (ART).

SNOMED

19030005, Human immunodeficiency virus | 62479008, Acquired immune deficieny syndrome

C0019693, HIV Infection | C0001175, Acquired Immunodeficiency Syndrome

risk_factor_comor

1

1

1

1

1

1

1

1

1

1

presentation

CO-MORBIDITIES AND RISK FACTORS: Existing prior to this current illness and is ongoing

comor_aids_art

radio

Is the patient on anti-retroviral therapy (ART)?

1, Yes | 0, No | 99, Unknown

[comor_aids] = ‘1’

Infection

Anti-retroviral therapy (ART) refers to drug therapy, for patients with HIV infection, which targets retrovirus function by multiple mechanisms to aggressively suppress HIV replication. It is distinct from pre-exposure prophylaxis (PrEP) or post-exposure prophylaxis (PEP).

Indicate the single most appropriate option that reflects the HIV/AIDS status of the patient and whether they are taking anti-retroviral therapy (ART).

SNOMED

416234007 |Highly active anti-retroviral therapy (procedure)|

C1963724, Antiretroviral therapy

risk_factor_comor

1

1

1

1

1

1

1

1

1

presentation

CO-MORBIDITIES AND RISK FACTORS: Existing prior to this current illness and is ongoing

comor_aids_arttype

text

Specify ART

[comor_aids_art] = ‘1’

Infection

This refers to antiretroviral therapy (ART) used in treatment of HIV infections with medications that target the virus directly, limiting the ability of infected cells to produce new virus particles. It is distinct from pre-exposure prophylaxis (PrEP) or post-exposure prophylaxis (PEP).

Write the antiretroviral therapy (ART) drugs being used in treatment of HIV.

SNOMED

416234007, Highly active anti-retroviral therapy (procedure)

risk_factor_comor

1

1

1

1

1

1

presentation

CO-MORBIDITIES AND RISK FACTORS: Existing prior to this current illness and is ongoing

comor_aids_cd4date

date_dmy

If HIV positive: CD4 count date

date_dmy

today

[comor_aids] = ‘1’

Infection

This refers to the date of the most recent laboratory-based CD4 cell count available.

Enter the date. (Use the format DD/MM/YYYY)

risk_factor_comor

1

1

1

1

1

1

presentation

CO-MORBIDITIES AND RISK FACTORS: Existing prior to this current illness and is ongoing

comor_aids_cd4count

number

If HIV positive: Most recent CD4 count (cells/µL)

number

1

10000

[comor_aids] = ‘1’

Infection

This refers to the date of the most recent laboratory-based CD4 cell count available.

Write the date in DD/MM/YYYY format.

risk_factor_comor

1

1

1

1

1

1

1

1

presentation

CO-MORBIDITIES AND RISK FACTORS: Existing prior to this current illness and is ongoing

comor_aids_vrl

radio

If HIV positive: Is HIV viral load detectable

1, Yes | 0, No | 99, Unknown

[comor_aids] = ‘1’

Infection

Detectable typically includes suppressed (detected but <= 1000 copies/mL) and unsuppressed (>1000 copies/mL). Undetectable refers to viral load not detected by test used.

Indicate ‘Yes’ if detectable (includes; suppressed (detected but <= 1000 copies/mL) and unsuppressed (>1000 copies/mL)). Indicate ‘No’ if undetectable (viral load not detected by test used).

SNOMED

165816005, Human immunodeficiency virus detected (finding)

risk_factor_comor

1

1

1

1

1

1

presentation

CO-MORBIDITIES AND RISK FACTORS: Existing prior to this current illness and is ongoing

comor_aids_vrlno

number

Most recent HIV viral load (copies/mL)

number

1

5000000

[comor_aids_vrl] = ‘1’

Infection

Defined as the most recent laboratory-based HIV viral load available expressed in copies/mL.

Indicate the most recent laboratory-based HIV viral load available expressed in copies/mL.

SNOMED

315124004, Human immunodeficiency virus viral load (procedure)

risk_factor_comor

1

1

1

1

1

1

presentation

CO-MORBIDITIES AND RISK FACTORS: Existing prior to this current illness and is ongoing

comor_aids_vrlnodate

date_dmy

HIV viral load date

date_dmy

Infection

This refers to the date of the most recent laboratory-based HIV viral load available.

Enter the date. (Use the format DD/MM/YYYY)

risk_factor_comor

1

1

presentation

CO-MORBIDITIES AND RISK FACTORS: Existing prior to this current illness and is ongoing

comor_tuberculos

radio

Tuberculosis

1, Yes | 0, No | 99, Unknown

Infection

Defined as patients currently receiving treatment for tuberculosis, an infection caused by the bacterium Mycobacterium tuberculosis. Latent tuberculosis should not be included here. Patients who have been cured of tuberculosis should not be included here. Those who have chronic pulmonary sequelae following their tuberculosis should be included as chronic pulmonary disease.

Indicate ‘Yes’, if this is condition existed prior to admission with this current illness and remains an active medical condition.

SNOMED

56717001, Tuberculosis

C0041296, Tuberculosis

risk_factor_comor

1

1

1

1

1

1

1

1

1

presentation

CO-MORBIDITIES AND RISK FACTORS: Existing prior to this current illness and is ongoing

comor_tuberculos_type

radio

Specify tuberculosis type

1, Active pulmonary | 4, Active extra-pulmonary | 3, Latent | 99, Unknown

[comor_tuberculos]=’1’

Infection

This refers to the type of Mycobacterium tuberculosis infection. Active pulmonary TB refers to bacterial infection that affects the lungs and is caused by Mycobacterium tuberculosis, with signs and symptoms including chronic cough with blood-tinged sputum, night sweats, fever, fatigue, and weight loss. Active extra-pulmonary TB refers to Mycobacterium tuberculosis infection involving organs other than the lungs (e.g., pleura, lymph nodes, abdomen, genitourinary tract, skin, joints and bones, or meninges). Latent TB refers to the asymptomatic presence of Mycobacterium tuberculosis in the body, which is determined by a positive result to a tuberculin skin test or interferon-gamma release assay.

Select the most appropriate option(s) that represents the type of Mycobacterium tuberculosis infection.

SNOMED

154283005, Pulmonary tuberculosis (disorder) | 423997002, Tuberculosis, extrapulmonary (disorder) | 11999007, Inactive tuberculosis (finding)

risk_factor_comor

1

1

1

1

1

1

presentation

CO-MORBIDITIES AND RISK FACTORS: Existing prior to this current illness and is ongoing

comor_hepbc

radio

Chronic hepatitis B/C infection

1, Yes | 0, No | 99, Unknown

Infection

Defined as chronic hepatitis due to infection by hepatitis B (HBV) or hepatitis C (HCV) virus. Do not include those with a documented cure of hepatitis C.

Indicate ‘Yes’, if this is condition existed prior to admission with this current illness and remains an active medical condition.

SNOMED

66870002 |Chronic active viral hepatitis (disorder)|

C0276625

risk_factor_comor

1

1

1

presentation

CO-MORBIDITIES AND RISK FACTORS: Existing prior to this current illness and is ongoing

comor_heme

descriptive

Haematological comorbidities

Haematology

This refers to comorbidities relating to the haematological system.

1

1

1

1

1

1

presentation

CO-MORBIDITIES AND RISK FACTORS: Existing prior to this current illness and is ongoing

comor_chrhematol

radio

Chronic haematologic disease

1, Yes | 0, No | 99, Unknown

Haematology

This refers to chronic disorders of the blood and blood forming tissues. Examples include Polycythemia Vera, Myelodysplastic Syndromes (MDS). Does not include leukaemia, lymphoma or myeloma, which should be entered under malignancy. Does not include iron-deficiency anaemia which is explained by diet or chronic blood loss.

Indicate ‘Yes’, if this is condition existed prior to admission with this current illness and remains an active medical condition.

SNOMED

398983000, Chronic disease of hematopoietic system

C1275398, Chronic disease of hematopoietic system

risk_factor_comor

1

1

1

1

1

1

presentation

CO-MORBIDITIES AND RISK FACTORS: Existing prior to this current illness and is ongoing

comor_recentblood

radio

Blood transfusion in last month

1, Yes | 0, No | 99, Unknown

Haematology

This refers to a history of previous blood transfusion within the past month of a calendar year.

Indicate ‘Yes’, if this is condition existed prior to admission with this current illness and remains an active medical condition.

1

presentation

CO-MORBIDITIES AND RISK FACTORS: Existing prior to this current illness and is ongoing

comor_sickle

radio

Sickle cell disease

1, Yes | 0, No | 99, Unknown

Haematology

This refers to a genetic blood disorder characterized by the appearance of sickle-shaped red blood cells and anemia.

Indicate ‘Yes’, if this is condition existed prior to admission with this current illness and remains an active medical condition.

presentation

CO-MORBIDITIES AND RISK FACTORS: Existing prior to this current illness and is ongoing

comor_sys

descriptive

Systemic / general comorbidities

Systemic/General

This refers to systemic / general comorbidities.

1

1

1

1

1

1

1

1

presentation

CO-MORBIDITIES AND RISK FACTORS: Existing prior to this current illness and is ongoing

comor_rheumatolo

radio

Rheumatologic disorder

1, Yes | 0, No | 99, Unknown

Systemic/General

Defined as an disorders of connective tissue, especially the joints and related structures characterised by inflammation, degeneration or metabolic derangement. It includes chronic arthropathies and arthritis, connective tissue disorders and vasculitides.

Indicate ‘Yes’, if this is condition existed prior to admission with this current illness and remains an active medical condition.

SNOMED

396332003 | Rheumatism (disorder) |

C0035435, Rheumatologic disorder

risk_factor_comor

1

1

1

1

1

1

1

1

1

presentation

CO-MORBIDITIES AND RISK FACTORS: Existing prior to this current illness and is ongoing

comor_rheumatolo_type

radio

Specify Rheumatologic disorder

1, Osteoarthritis| 2,Rheumatoid Arthritis| 3, Systemic Lupus Erythematosus | 4, Ankylosing Spondylitis | 5, Psoriatic Arthritis | 99, Unknown | 88, Other

[comor_rheumatolo] = ‘1’

1

presentation

CO-MORBIDITIES AND RISK FACTORS: Existing prior to this current illness and is ongoing

comor_rheumatolo_type_oth

text

Specify Other Rheumatologic disorder

[comor_rheumatolo_type] = ‘88’

1

presentation

CO-MORBIDITIES AND RISK FACTORS: Existing prior to this current illness and is ongoing

comor_asplenia

radio

Asplenia

1, Yes | 0, No | 99, Unknown

Systemic/General

Defined as the anatomical absence of the spleen or functional asplenia secondary to a variety of disease states. This can include congenital absence (born without a spleen), or acquired absence, for example secondary to surgical removal.

Indicate ‘Yes’, if this is condition existed prior to admission with this current illness and remains an active medical condition.

SNOMED

707147002, Asplenia

CL534652, asplenia following surgical procedure; C3810472, Congenital absence of spleen; C0272405 functional asplenia

risk_factor_comor

1

1

1

1

1

1

1

1

presentation

CO-MORBIDITIES AND RISK FACTORS: Existing prior to this current illness and is ongoing

comor_benignn

radio

Benign neoplasm

1, Yes | 0, No | 99, Unknown

Systemic/General

This refers to a neoplasm characterized by the absence of atypical or malignant cytological and architectural features, and absence of invasive features or metastatic potential.

Indicate ‘Yes’, if this is condition existed prior to admission with this current illness and remains an active medical condition.

SNOMED

20376005, Benign neoplastic disease (disorder)

C0086692, Benign Neoplasm

risk_factor_comor

1

1

presentation

CO-MORBIDITIES AND RISK FACTORS: Existing prior to this current illness and is ongoing

comor_malignantn

radio

Malignant neoplasm

1, Yes | 0, No | 99, Unknown

Systemic/General

Defined as a tumour composed of atypical neoplastic, often pleomorphic cells that invade other tissues. Includes haematological malignancies, that are considered to be biologically active. The most common malignant neoplasms are carcinomas (adenocarcinomas or squamous cell carcinomas), Hodgkin and non-Hodgkin lymphomas, leukaemias, melanomas, and sarcomas. It specifically does not include malignancies that have been cured or where there is no evidence of on-going disease relating to that malignancy following treatment.

Indicate ‘Yes’, if this is condition existed prior to admission with this current illness and remains an active medical condition.

SNOMED

363346000, Malignant neoplastic disease

C1861853, Malignant Neoplasm

risk_factor_comor

1

1

1

1

1

1

1

1

presentation

CO-MORBIDITIES AND RISK FACTORS: Existing prior to this current illness and is ongoing

comor_malignantn_sol

radio

Malignant solid neoplasm

1, Yes | 0, No | 99, Unknown

[comor_malignantn]=’1’

Systemic/General

Defined as a malignant neoplasm arising from solid tissues that do not include fluid areas (e.g., blood or bone marrow). Representative examples include carcinomas (adenocarcinomas or squamous cell carcinomas) and sarcomas. Hematopoietic and lymphoid tissue malignancies are not considered solid neoplasms and are covered as leukaemia and lymphoma below.

Indicate ‘Yes’, if this is condition existed prior to admission with this current illness and remains an active medical condition.

risk_factor_comor

1

1

presentation

CO-MORBIDITIES AND RISK FACTORS: Existing prior to this current illness and is ongoing

comor_malignantn_leuk

radio

Leukemia

1, Yes | 0, No | 99, Unknown

[comor_malignantn]=’1’

Systemic/General

Defined as a progressive, malignant disease of the blood-forming organs, characterized by distorted proliferation and development of leukocytes and their precursors in the blood and bone marrow. Leukemias were originally termed acute or chronic based on life expectancy but now are classified according to cellular maturity.

Indicate ‘Yes’, if this is condition existed prior to admission with this current illness and remains an active medical condition.

SNOMED

93143009, Leukemia, disease (disorder)

C0023418, leukemia

risk_factor_comor

1

1

presentation

CO-MORBIDITIES AND RISK FACTORS: Existing prior to this current illness and is ongoing

comor_malignantn_lymp

radio

Lymphoma

1, Yes | 0, No | 99, Unknown

[comor_malignantn]=’1’

Systemic/General

Defined as a malignant (clonal) proliferation of B- lymphocytes or T- lymphocytes which involves the lymph nodes, bone marrow and/or extranodal sites. This category includes Non-Hodgkin lymphomas and Hodgkin lymphomas.

Indicate ‘Yes’, if this is condition existed prior to admission with this current illness and remains an active medical condition.

SNOMED

118600007, Malignant lymphoma (disorder)

C0024299, Lymphoma

risk_factor_comor

1

1

presentation

CO-MORBIDITIES AND RISK FACTORS: Existing prior to this current illness and is ongoing

comor_obesity

radio

Obesity

1, Yes | 0, No | 99, Unknown

Systemic/General

Refers to body weight grossly above recommended standard. BMI >= 30 kg/m2 or other locally appropriate BMI cut off can be used to define obesity.

Indicate ‘Yes’, if this is condition existed prior to admission with this current illness and remains an active medical condition.

SNOMED

414916001, Obesity (disorder)

C3809449, Obesity

risk_factor_comor

1

1

1

1

1

1

1

presentation

CO-MORBIDITIES AND RISK FACTORS: Existing prior to this current illness and is ongoing

comor_malnutriti

radio

Malnutrition

1, Yes | 0, No | 99, Unknown

Systemic/General

This refers to any clinically identified deficiency in intake, either of total energy or of specific nutrients, that led to a dietetic intervention or referral prior to this admission.

Indicate ‘Yes’, if this is condition existed prior to admission with this current illness and remains an active medical condition.

SNOMED

2492009, Nutritional disorder (disorder)

CL1378604, Malnutrition

risk_factor_comor

1

1

1

1

1

1

1

1

presentation

CO-MORBIDITIES AND RISK FACTORS: Existing prior to this current illness and is ongoing

comor_diabetes

radio

Diabetes mellitus

1, Yes | 0, No | 99, Unknown

Systemic/General

Defined as a metabolic disorder characterized by abnormally high blood sugar levels due to diminished production of insulin or insulin resistance or desensitization. This includes Type 1 diabetes mellitus, Type 2 diabetes mellitus, or Gestational diabetes (during previous pregnancy) requiring oral or subcutaneous treatment.

Indicate ‘Yes’, if this is condition existed prior to admission with this current illness and remains an active medical condition.

SNOMED

73211009, Diabetes mellitus (disorder)

C4013416, Diabetes mellitus

risk_factor_comor

1

1

1

1

1

1

1

1

1

1

presentation

CO-MORBIDITIES AND RISK FACTORS: Existing prior to this current illness and is ongoing

comor_diabetes_type

radio

Diabetes mellitus type

1, Type 1| 2, Type 2 | 3, Gestational diabetes | 99, Unknown

[comor_diabetes] = ‘1’

Systemic/General

Refers to a subtype of diabetes mellitus that is characterized by insulin deficiency; it is manifested by the sudden onset of severe hyperglycemia, rapid progression to diabetic ketoacidosis, and death unless treated with insulin; the disease may occur at any age, but is most common in childhood or adolescence.

Indicate ‘Yes’, if this is condition existed prior to admission with this current illness and remains an active medical condition.

SNOMED

46635009, Diabetes mellitus type 1 (disorder)

C5435660, TYPE 1 DIABETES MELLITUS 1

risk_factor_comor

1

1

1

1

1

1

1

1

presentation

CO-MORBIDITIES AND RISK FACTORS: Existing prior to this current illness and is ongoing

comor_diabetes_endorg

radio

End organ damage from diabetes

1, Yes | 0, No | 99, Unknown

[comor_diabetes] = ‘1’

Systemic/General

Refers to irreparable damage to multiple organs/systems which is the result of chronic complications of diabetes. The affected organs/systems include the cardiovascular system, kidneys, eyes, nervous system, joints and feet.

Indicate ‘Yes’, if this is condition existed prior to admission with this current illness and remains an active medical condition.

C3830315, End Organ Damage from Diabetes

risk_factor_comor

1

1

1

presentation

CO-MORBIDITIES AND RISK FACTORS: Existing prior to this current illness and is ongoing

comor_hba1c

number

HbA1C result within last 6 months

number

[comor_diabetes] = ‘1’

Systemic/General

Haemoglobin A1C (HbA1C) is a blood test that measures average blood glucose level over the three months preceding the test result. It can be reported in different units (mmol/mol or %).

Enter the numerical value for HbA1C level. If there is no result for the patient in the last six months proceed onto the next question.

SNOMED

43396009, Hemoglobin A1c measurement (procedure)

C0474680, Hemoglobin A1c measurement

risk_factor_comor

1

1

1

1

presentation

CO-MORBIDITIES AND RISK FACTORS: Existing prior to this current illness and is ongoing

comor_hba1c_units

radio

HbA1C result within last 6 months (select units)

1, mmol/mol | 2, %

units

[comor_diabetes] = ‘1’

Systemic/General

SNOMED

43396009, Hemoglobin A1c measurement (procedure)

C0474680, Hemoglobin A1c measurement

risk_factor_comor

1

1

1

presentation

CO-MORBIDITIES AND RISK FACTORS: Existing prior to this current illness and is ongoing

comor_hba1c_mmolmol

number

HbA1C result within last 6 months (mmol/mol)

number

[comor_diabetes] = ‘1’

Systemic/General

Haemoglobin A1C (HbA1C) is a blood test that measures average blood glucose level over the three months preceding the test result. It can be reported in different units (mmol/mol or %).

Enter the numerical value for HbA1C level expressed in mmol/mol. If there is no result for the patient in the last six months proceed onto the next question.

SNOMED

43396009, Hemoglobin A1c measurement (procedure)

C0474680, Hemoglobin A1c measurement

risk_factor_comor

1

1

1

1

presentation

CO-MORBIDITIES AND RISK FACTORS: Existing prior to this current illness and is ongoing

comor_hba1c_pcnt

number

HbA1C results within last 6 months (%)

number

0

100

[comor_diabetes] = ‘1’

Systemic/General

Haemoglobin A1C (HbA1C) is a blood test that measures average blood glucose level over the three months preceding the test result. It can be reported in different units (mmol/mol or %).

Enter the numerical value for HbA1C level expressed as a percentage (%). If there is no result for the patient in the last six months proceed onto the next question.

SNOMED

43396009, Hemoglobin A1c measurement (procedure)

risk_factor_comor

1

1

1

presentation

CO-MORBIDITIES AND RISK FACTORS: Existing prior to this current illness and is ongoing

comor_smoking

radio

Ever smoked

1, Yes | 0, No | 99, Unknown

[demog_calcage_days]>4745

Systemic/General

This refers to smoking cigarettes, cigars, pipes or equivalent. Never smoker is defined as a person who has never smoked at the time of the assessment or has smoked less than 100 of the above items in their life. Do not include smoke-free tobacco products such as chewed tobacco or electronic nicotine delivery devices.

Indicate ‘Yes’, if this is condition existed prior to admission with this current illness and remains an active medical condition. Indicate ‘No’ if the patient has never smoked (defined as a person who has never smoked at the time of the assessment or has smoked less than 1 of the above items in their life).

SNOMED

77176002, Smoker (finding) | 266919005, Never smoked tobacco (finding)

C0302836, Smoking tobacco | C0425293, Never Smoker

risk_factor_comor

1

1

1

1

1

1

1

1

1

presentation

CO-MORBIDITIES AND RISK FACTORS: Existing prior to this current illness and is ongoing

comor_smoking_type

radio

Smoking status

1, Current smoker | 2, Former Smoker

[comor_smoking]=’1’

Systemic/General

This refers to smoking cigarettes, cigars, pipes or equivalent. Never smoker is defined as a person who has never smoked at the time of the assessment or has smoked less than 100 of the above items in their life. Do not include smoke-free tobacco products such as chewed tobacco or electronic nicotine delivery devices.

Indicate ‘Yes’, if this is condition existed prior to admission with this current illness and remains an active medical condition. Indicate ‘No’ if the patient has never smoked (defined as a person who has never smoked at the time of the assessment or has smoked less than 1 of the above items in their life).

SNOMED

77176002, Smoker (finding) | 266919005, Never smoked tobacco (finding)

C0302836, Smoking tobacco | C0425293, Never Smoker

risk_factor_comor

1

1

1

1

1

1

1

1

1

presentation

CO-MORBIDITIES AND RISK FACTORS: Existing prior to this current illness and is ongoing

comor_smoking_passive

radio

Passive smoking (lives in same household as a smoker)

1, Yes | 0, No | 99, Unknown

Systemic/General

This refers to increased risk of exposure to tobacco smoke products among individuals who do not smoke. This can result from sharing space with a smoker or from placental transfer from mother to fetus.

Indicate ‘Yes’, if this is condition existed prior to admission with this current illness and remains an active medical condition.

presentation

CO-MORBIDITIES AND RISK FACTORS: Existing prior to this current illness and is ongoing

comor_orgtrans

radio

Transplant recipient

1, Yes | 0, No | 99, Unknown

Systemic/General

This refers to an individual receiving (or has received) tissues or organs transferred from another individual of the same or different species, or from within the same individual.

Indicate ‘Yes’, if this is condition existed prior to admission with this current illness and remains an active medical condition.

SNOMED

737294004, Transplant present

risk_factor_comor

1

1

1

1

1

presentation

CO-MORBIDITIES AND RISK FACTORS: Existing prior to this current illness and is ongoing

comor_orgtrans_organ

checkbox

Specify transplanted organ(s)

1, Lung | 2, Heart | 3, Kidney | 4, Liver | 5, Bone | 6, Hematopoietic stem cell

[comor_orgtrans]=’1’

Systemic/General

This refers to the specific tissue(s) or organ(s) transferred from another individual of the same or different species, or from within the same individual.

Select all that apply.

risk_factor_comor

1

1

1

1

presentation

CO-MORBIDITIES AND RISK FACTORS: Existing prior to this current illness and is ongoing

comor_primaryimmuno

radio

Primary immunodeficiency

1, Yes | 0, No | 99, Unknown

Systemic/General

This refers to immunodeficiency disease that arises independent of another pathologic process, disease, or injury.

Indicate ‘Yes’, if this is condition existed prior to admission with this current illness and remains an active medical condition.

risk_factor_comor

1

presentation

CO-MORBIDITIES AND RISK FACTORS: Existing prior to this current illness and is ongoing

comor_chemotherapy

radio

Chemotherapy

1, Yes | 0, No | 99, Unknown

Systemic/General

This refers to treatment that uses drugs to stop the growth of cancer cells, either by killing the cells or by stopping them from dividing.

Indicate ‘Yes’, if this is condition existed prior to admission with this current illness and remains an active medical condition.

1

1

1

presentation

CO-MORBIDITIES AND RISK FACTORS: Existing prior to this current illness and is ongoing

comor_radiotherapy

radio

Radiation therapy

1, Yes | 0, No | 99, Unknown

Systemic/General

This refers to the use of high-energy radiation from x-rays, gamma rays, neutrons, protons, and other sources to kill cancer cells and shrink tumors.

Indicate ‘Yes’, if this is condition existed prior to admission with this current illness and remains an active medical condition.

1

1

1

presentation

CO-MORBIDITIES AND RISK FACTORS: Existing prior to this current illness and is ongoing

comor_steroidtherapy

radio

Long term or high-dose corticosteroid therapy

1, Yes | 0, No | 99, Unknown

Systemic/General

This refers to use of exogenous corticosteroids in high-doses or for long term (typically for over 4 weeks) periods for the treatment of any disease or disorder.

Indicate ‘Yes’, if this is condition existed prior to admission with this current illness and remains an active medical condition.

1

1

1

presentation

CO-MORBIDITIES AND RISK FACTORS: Existing prior to this current illness and is ongoing

comor_skincon

radio

Relevant skin condition(s) (atopic dermatitis or active exfoliative skin conditions)

1, Yes | 0, No | 99, Unknown

Skin

This refers to any deviation from the normal structure or function of the skin or subcutaneous tissue that is manifested by a characteristic set of symptoms and signs.

Indicate ‘Yes’, if this is condition existed prior to admission with this current illness and remains an active medical condition.

SNOMED

95320005, Disorder of skin (disorder)

risk_factor_comor

1

presentation

CO-MORBIDITIES AND RISK FACTORS: Existing prior to this current illness and is ongoing

comor_skincondesc

text

Describe the skin condition(s)

Skin

This refers to any deviation from the normal structure or function of the skin or subcutaneous tissue that is manifested by a characteristic set of symptoms and signs.

If ‘Yes’, please give a description of the skin condition(s).

SNOMED

95320005, Disorder of skin (disorder)

risk_factor_comor

1

presentation

CO-MORBIDITIES AND RISK FACTORS: Existing prior to this current illness and is ongoing

comor_paed

descriptive

Paediatric-specific Comorbidities

[demog_calcage_days]<=730

Paediatric

1

1

presentation

CO-MORBIDITIES AND RISK FACTORS: Existing prior to this current illness and is ongoing

comor_premature

radio

Prematurity (<37 weeks)

1, Yes | 0, No | 99, Unknown

[demog_calcage_days]<=730

Paediatric

1

1

presentation

CO-MORBIDITIES AND RISK FACTORS: Existing prior to this current illness and is ongoing

comor_malnut_assess

descriptive

Malnutrition assessment

Systemic/General

This refers to any clinically identified deficiency in intake, either of total energy or of specific nutrients, that led to a dietetic intervention or referral prior to this admission.

Indicate ‘Yes’, if this is condition existed prior to admission with this current illness and remains an active medical condition.

SNOMED

2492009, Nutritional disorder (disorder)

CL1378604, Malnutrition

risk_factor_comor

1

presentation

CO-MORBIDITIES AND RISK FACTORS: Existing prior to this current illness and is ongoing

comor_malnut_muac

number

Mid-Upper Arm Circumference

number

[demog_calcage_days]<=5844

1

presentation

CO-MORBIDITIES AND RISK FACTORS: Existing prior to this current illness and is ongoing

comor_malnut_acuteill

radio

Acute illness in past 3 months

1, Yes | 0, No | 99, Unknown

[demog_calcage_days]>23725

1

presentation

CO-MORBIDITIES AND RISK FACTORS: Existing prior to this current illness and is ongoing

comor_malnut_fintake65

radio

Decline in food intake past 3 months (appetite, digestion, chewing/swallowing difficulties)

1, Yes | 0, No | 99, Unknown

1

presentation

CO-MORBIDITIES AND RISK FACTORS: Existing prior to this current illness and is ongoing

comor_malnut_wtloss65

radio

Weight loss during past 3 months

1, Weight loss greater than 3 kg (6.6 lbs) | 3, Weight loss between 1 and 3 kg (2.2 and 6.6 lbs) | 0, No weight loss | 99, Unknow

1

presentation

CO-MORBIDITIES AND RISK FACTORS: Existing prior to this current illness and is ongoing

comor_malnut_psychstress65

radio

Psychological stress in past 3 months

1, Yes | 0, No | 99, Unknown

1

presentation

CO-MORBIDITIES AND RISK FACTORS: Existing prior to this current illness and is ongoing

comor_otherdesc

descriptive

Other comorbidities

Other

1

1

1

1

1

1

1

1

presentation

CO-MORBIDITIES AND RISK FACTORS: Existing prior to this current illness and is ongoing

comor_unlisted

list

Other relevant comorbidity(s)

1, Yes | 0, No | 99, Unknown

conditions_Comorbidities

Other

This refers to a comorbid condition(s) not listed above.

Indicate ‘Yes’, if this is condition(s) existed prior to admission with this current illness and remains an active medical condition.

SNOMED

398192003, Co-morbid conditions (finding)

risk_factor_comor

1

1

1

1

1

1

1

1

1

presentation

CO-MORBIDITIES AND RISK FACTORS: Existing prior to this current illness and is ongoing

comor_mhdesc

descriptive

Current Acute Conditions

1

1

1

presentation

CO-MORBIDITIES AND RISK FACTORS: Existing prior to this current illness and is ongoing

medic_cpox

radio

Active chickenpox

1, Yes | 0, No | 99, Unknown

This refers to active chickenpox infection caused by varicella-zoster virus. Clinical manifestations are fever and pruritic, vesicular skin rash occurring ten to twenty-one days after exposure. Do not include those with reactived Varicella zoster virus (VZV) i.e. Shingles.

Indicate ‘Yes’, if this is condition existed prior to admission with this current illness and remains an active medical condition.

SNOMED

38907003, Varicella (disorder)

C0008049, Chicken Pox

1

1

1

presentation

CO-MORBIDITIES AND RISK FACTORS: Existing prior to this current illness and is ongoing

medic_meas

radio

Active measles

1, Yes | 0, No | 99, Unknown

Indicate ‘Yes’, if this is condition existed prior to admission with this current illness and remains an active medical condition.

SNOMED

1

presentation

CO-MORBIDITIES AND RISK FACTORS: Existing prior to this current illness and is ongoing

medic_actshingles

radio

Active shingles (herpes zoster)

1, Yes | 0, No | 99, Unknown

This refers to an active case of shingles or herpes zoster dues to the reactivation of the varicella-zoster virus that has remained dormant, after the patient’s initial exposure to the virus in the form of varicella (chickenpox).

Indicate ‘Yes’, if the patient currently has shingles (herpes zoster), a reactivation of varicella-zoster virus. Indicate ‘No’ if the patient has only had chickenpox in the past, or if the patient does not have a history of this condition.

SNOMED

4740000 | Herpes zoster (disorder) |

C0019360, Herpes zoster

1

1

1

presentation

CO-MORBIDITIES AND RISK FACTORS: Existing prior to this current illness and is ongoing

medic_acthcv

radio

Active Hepatitis C

1, Yes | 0, No | 99, Unknown

This refers to an active case of hepatitis C virus infection.

Indicate ‘Yes’, if the patient currently has active hepatitis C infection

1

presentation

CO-MORBIDITIES AND RISK FACTORS: Existing prior to this current illness and is ongoing

medic_acthbv

radio

Active Hepatitis B

1, Yes | 0, No | 99, Unknown

This refers to an active case of hepatitis B virus infection.

Indicate ‘Yes’, if the patient currently has active hepatitis B infection

1

presentation

CO-MORBIDITIES AND RISK FACTORS: Existing prior to this current illness and is ongoing

medic_sti

radio

Active sexually transmitted infection

1, Yes | 0, No | 99, Unknown

Defined as infections due to or propagated by sexual contact including, chlamydia, genital herpes/warts, gonorrhea, HPV, public lice, syphilis, trichomoniasis, lymphogranuloma venereum. Do not include HIV/AIDS and chronic hepatitis, as specified in separate questions.

Indicate ‘Yes’, if this is condition existed prior to admission with this current illness and remains an active medical condition.

SNOMED

8098009, Sexually transmitted infectious disease (disorder)

CL1399179, Sexually transmitted infections

1

1

presentation

CO-MORBIDITIES AND RISK FACTORS: Existing prior to this current illness and is ongoing

medic_sti_type

checkbox

Specify active STI

1, Herpes Simplex Virus (HSV) | 2, Human Papillomavirus (HPV) | 3, Chlamydia | 4, Gonorrhoea | 5, Syphilis | 6, Mycoplasma genitalium | 99, Unknown | 88, Other

[medic_sti]=’1’

Defined as infections due to or propagated by sexual contact including, chlamydia, genital herpes/warts, gonorrhea, HPV, public lice, syphilis, trichomoniasis, lymphogranuloma venereum. Do not include HIV/AIDS and chronic hepatitis, as specified in separate questions.

Select all that apply.

SNOMED

721585006, Sexually transmissible infection caused by Herpes simplex virus (disorder) | 240532009, Human papillomavirus infection (disorder) | 105629000, Chlamydial infection (disorder) | 15628003, Gonorrhea (disorder) | 76272004, Syphilis (disorder) | 1163504003, Infection caused by Mycoplasma genitalium (disorder)

1

1

presentation

CO-MORBIDITIES AND RISK FACTORS: Existing prior to this current illness and is ongoing

medic_sti_oth

text

specify other active STI

[medic_sti_type(88)]=’1’

Defined as infections due to or propagated by sexual contact including, not listed above. Do not include HIV/AIDS and chronic hepatitis, as specified in separate questions.

If ‘Other’, specify the other active STI.

SNOMED

8098009, Sexually transmitted infectious disease (disorder)

1

1

presentation

MEDICAL HISTORY

medic_previnf

radio

Is the patient known to have had previous infection(s) with this pathogen?

1, Yes | 0, No | 99, Unknown

Defined as a previous diagnosis with the same pathogen in a clinical episode distinct from this presentation or admission.

Indicate ‘Yes’, if the patient has previously been infected with the same pathogen.

1

1

1

1

1

1

presentation

MEDICAL HISTORY

medic_firstadm

radio

Was the patient ever hospitalised in a previous episode of the same infection?

1, Yes-admitted to hospital or ICU | 0, No | 99, Unknown

[medic_previnf] = ‘1’

This refers to the patient’s previous history of infection(s) with the same pathogen and whether the patient was ever admitted to hospital or ICU.

Indicate ‘Yes’ if the patient was admitted to hospital or ICU for infection with the same pathogen.

1

1

1

presentation

MEDICAL HISTORY

medic_infstartdate

date_dmy

When did the previous episode begin?

date_dmy

today

[medic_previnf]=’1’

This refers to the exact date (or approximate date, if not known) when the previous episode of infection with the same pathogen begun.

Enter the exact date at which the previous infection with the same pathogen begun. If the precise date is unknown, enter an estimate. (Use the format DD/MM/YYYY)

1

1

1

1

1

presentation

MEDICAL HISTORY

medic_infenddate

date_dmy

When did the previous episode end?

date_dmy

today

[medic_previnf]=’1’

This refers to the exact date (or approximate date, if not known) when the previous episode of infection with the same pathogen ended.

Enter the exact date at which the previous infection with the same pathogen ended. If the precise date is unknown, enter an estimate. (Use the format DD/MM/YYYY)

1

1

1

1

1

presentation

MEDICAL HISTORY

medic_labtest

radio

Was the previous episode confirmed by laboratory testing?

1, Yes | 0, No | 99, Unknown

[medic_previnf]=’1’

This refers to confirmation of the previous infection episode with a laboratory test.

Indicate ‘Yes’, if the previous episode was confirmed with laboratory testing.

1

1

1

1

1

presentation

MEDICAL HISTORY

medic_previnf2

radio

Is the patient known to have had an infection(s) before the last reported with this pathogen?

1, Yes | 0, No | 99, Unknown

Defined as a previous diagnosis with the same pathogen in a clinical episode before the last reported infection.

Indicate ‘Yes’, if the patient has previously had an infection with the same pathogen in a clinical episode before the last reported infection.

1

presentation

MEDICAL HISTORY

medic_previnf2_adm

radio

Was the patient ever hospitalised in this previous episode of the same infection?

1, Yes-admitted to hospital or ICU | 0, No | 99, Unknown

[medic_previnf2] = ‘1’

This refers to the patient’s previous history of infection with the same pathogen and whether the patient was ever admitted to hospital or ICU.

Indicate ‘Yes’ if the patient was admitted to hospital or ICU for an infection with the same pathogen in a clinical episode before the last reported infection.

1

presentation

MEDICAL HISTORY

medic_previnf2_startdate

date_dmy

When did this previous episode begin?

date_dmy

today

[medic_previnf2]=’1’

This refers to the exact date (or approximate date, if not known) when the previous episode of infection with the same pathogen begun.

Enter the exact date at which the previous infection with the same pathogen begun. If the precise date is unknown, enter an estimate. (Use the format DD/MM/YYYY)

1

presentation

MEDICAL HISTORY

medic_previnf2_enddate

date_dmy

When did this previous episode end?

date_dmy

today

[medic_previnf2]=’1’

This refers to the exact date (or approximate date, if not known) when the previous episode of infection with the same pathogen ended.

Enter the exact date at which the previous infection with the same pathogen ended. If the precise date is unknown, enter an estimate. (Use the format DD/MM/YYYY)

1

presentation

MEDICAL HISTORY

medic_previnf3

radio

Is the patient known to have had an infection(s) before the last reported with this pathogen?

1, Yes | 0, No | 99, Unknown

Defined as a previous diagnosis with the same pathogen in a clinical episode before the last reported infection.

Indicate ‘Yes’, if the patient has previously had an infection with the same pathogen in a clinical episode before the last reported infection.

1

presentation

MEDICAL HISTORY

medic_previnf3_adm

radio

Was the patient ever hospitalised in this previous episode of the same infection?

1, Yes-admitted to hospital or ICU | 0, No | 99, Unknown

[medic_previnf3] = ‘1’

This refers to the patient’s previous history of infection with the same pathogen and whether the patient was ever admitted to hospital or ICU.

Indicate ‘Yes’ if the patient was admitted to hospital or ICU for an infection with the same pathogen in a clinical episode before the last reported infection.

1

presentation

MEDICAL HISTORY

medic_previnf3_startdate

date_dmy

When did this previous episode begin?

date_dmy

today

[medic_previnf3] = ‘1’

This refers to the exact date (or approximate date, if not known) when the previous episode of infection with the same pathogen begun.

Enter the exact date at which the previous infection with the same pathogen begun. If the precise date is unknown, enter an estimate. (Use the format DD/MM/YYYY)

1

presentation

MEDICAL HISTORY

medic_previnf3_enddate

date_dmy

When did this previous episode end?

date_dmy

today

[medic_previnf3] = ‘1’

This refers to the exact date (or approximate date, if not known) when the previous episode of infection with the same pathogen ended.

Enter the exact date at which the previous infection with the same pathogen ended. If the precise date is unknown, enter an estimate. (Use the format DD/MM/YYYY)

1

presentation

MEDICAL HISTORY

medic_cpoxpast

radio

Known to have previous chickenpox infection(s)?

1, Yes | 0, No | 99, Unknown

This refers to a previous chickenpox infection. It does not include a history of reactived Varicella zoster virus (VZV) i.e. Shingles.

Indicate ‘Yes’, if this is condition existed prior to admission with this current illness and remains an active medical condition.

SNOMED

161423008, History of chickenpox (situation)

C0455469, H/O: chickenpox

1

1

presentation

MEDICATION PRIOR TO THIS ADMISSION / PRESENTATION

drug14_antiviral

radio

Antiviral

1, Yes | 0, No | 99, Unknown

An antiviral agent refers to any agent(s) prescribed to treat or prevent viral infections by interfering with the viral replication cycle. Examples of neuraminidase inhibitors include oseltamivir, ribavirin, acyclovir and lopinavir/ritonavir. Topical preparations are not included.

Indicate ‘Yes’, if the patient has taken an antiviral in the 14 days prior to this most recent admission / presentation

1

1

1

1

1

1

presentation

MEDICATION PRIOR TO THIS ADMISSION / PRESENTATION

drug14_antiviral_type

multi_list

Antiviral

drugs_Antiviral

[drug14_antiviral] = ‘1’

An antiviral agent refers to any agent(s) prescribed to treat or prevent viral infections by interfering with the viral replication cycle. Examples of neuraminidase inhibitors include oseltamivir, ribavirin, acyclovir and lopinavir/ritonavir. Topical preparations are not included.

Select the antiviral(s) prescribed or taken by the patient in the 14 days prior to this most recent admission / presentation

SNOMED

788081006, Medicinal product acting as antiviral agent (product)|

C0003451, Antiviral agent

1

1

1

1

1

1

presentation

MEDICATION PRIOR TO THIS ADMISSION / PRESENTATION

drug14_antiviral_route

checkbox

Antiviral administration route

1, Oral | 2, Inhaled | 3, IV | 4, Topical | 99, Unknown

[drug14_antiviral] = ‘1’

This refers to the part of the body through which or into which, or the way in which, the medicinal product (drug) is introduced. Oral refers to administering by mouth. Inhaled refers to administration through the respiratory route (insufflation into the respiratory tract). IV (intravenous) refers to administering into bloodstream through injection into a vein. Topical refers to administration by application of drug preparations to the surfaces of the body, especially the skin or mucous membranes.

Indicate the route of administration for the antiviral agent.

SNOMED

386359008, Administration of drug or medicament via oral route (procedure) | 243132000, Inhaled drug administration (procedure) | 386358000, Administration of drug or medicament via intravenous route (procedure) | 431695009, Administration of drug or medicament to skin via topical route (procedure)

1

1

presentation

MEDICATION PRIOR TO THIS ADMISSION / PRESENTATION

drug14_antiviraldate

date_dmy

Antiviral start date

date_dmy

today

[drug14_antiviral] = ‘1’

This refers to the date the medication was started / first dose was administered.

Enter the date when the medication was started / first dose was given. If the precise date is unknown, enter an estimate. (Use the format DD/MM/YYYY)

1

1

1

1

1

presentation

MEDICATION PRIOR TO THIS ADMISSION / PRESENTATION

drug14_antiviralday

number

Number of days antivirals taken

number

0

[drug14_antiviral] = ‘1’

Includes all calendar days in which a dose was received or instructed to take on discharge prescription.

Enter the total number of days for which a dose was received or instructed to take on discharge prescription.

1

1

1

1

1

1

presentation

MEDICATION PRIOR TO THIS ADMISSION / PRESENTATION

drug14_steroid

radio

Corticosteroid

1, Yes | 0, No | 99, Unknown

Corticosteroids (commonly referred to as ‘steroids’) refers to all types of therapeutic corticosteroid, made in the adrenal cortex (the outer part of the adrenal gland). They are also made in the laboratory. Examples include: prednisolone, prednisone, methyl-prednisolone, dexamethasone, hydrocortisone, fluticasone, betametasone. Topical preparations are not included, but inhaled preparations are included.

Indicate ‘Yes’, if the patient has taken a ‘steroid’ in the 14 days prior to this most recent admission / presentation

SNOMED

788326005, Product containing adrenal cortex hormone (product)|

CL554601, Therapeutic corticosteroid

1

1

1

1

1

1

1

1

1

presentation

MEDICATION PRIOR TO THIS ADMISSION / PRESENTATION

drug14_steroid_type

multi_list

Corticosteroid

drugs_Steroids

[drug14_steroid]=’1’

Corticosteroids (commonly referred to as ‘steroids’) refers to all types of therapeutic corticosteroid, made in the adrenal cortex (the outer part of the adrenal gland). They are also made in the laboratory. Examples include: prednisolone, prednisone, methyl-prednisolone, dexamethasone, hydrocortisone, fluticasone, betametasone. Topical preparations are not included, but inhaled preparations are included.

Select the corticosteroids(s) prescribed or taken by the patient in the 14 days prior to this most recent admission / presentation

SNOMED

788326005, Product containing adrenal cortex hormone (product)|

CL554601, Therapeutic corticosteroid

1

1

1

1

1

1

1

1

1

presentation

MEDICATION PRIOR TO THIS ADMISSION / PRESENTATION

drug14_steroid_route

checkbox

Corticosteroid administration route

1, Oral | 2, Inhaled | 3, IV | 99, Unknown

[drug14_steroid]=’1’

This refers to the part of the body through which or into which, or the way in which, the medicinal product (drug) is introduced. Oral refers to administering by mouth. Inhaled refers to administration through the respiratory route (insufflation into the respiratory tract). IV (intravenous) refers to administering into bloodstream through injection into a vein. Topical refers to administration by application of drug preparations to the surfaces of the body, especially the skin or mucous membranes.

Indicate the route of administration for the corticosteroid.

SNOMED

386359008, Administration of drug or medicament via oral route (procedure) | 243132000, Inhaled drug administration (procedure) | 386358000, Administration of drug or medicament via intravenous route (procedure) | 431695009, Administration of drug or medicament to skin via topical route (procedure)

1

1

1

1

1

1

1

presentation

MEDICATION PRIOR TO THIS ADMISSION / PRESENTATION

drug14_steroid_date

date_dmy

Corticoteroid start date

date_dmy

today

[drug14_steroid]=’1’

This refers to the date the medication was started / first dose was administered.

Enter the date when the medication was started / first dose was given. If the precise date is unknown, enter an estimate. (Use the format DD/MM/YYYY)

1

1

1

1

1

1

presentation

MEDICATION PRIOR TO THIS ADMISSION / PRESENTATION

drug14_steroid_day

number

Number of days corticosteroid taken

number

0

[drug14_steroid]=’1’

Includes all calendar days in which a dose was received or instructed to take on discharge prescription.

Enter the total number of days for which a dose was received or instructed to take on discharge prescription.

1

1

1

1

1

1

1

presentation

MEDICATION PRIOR TO THIS ADMISSION / PRESENTATION

drug14_steroid_dose

number

Dose of corticosteroid

number

0

[drug14_steroid]=’1’

This refers to the dose of the corticosteroid agent.

Indicate the dose of the corticosteroid agent.

1

1

1

presentation

MEDICATION PRIOR TO THIS ADMISSION / PRESENTATION

drug14_immunusupp

radio

Immunosuppressant agents (not corticosteroids)

1, Yes | 0, No | 99, Unknown

This refers to a patient who is known to have taken prescribed medications that are known to have an immunosuppressing effect (excluding steroids/corticosteroids). Topical preparations should not be recorded.

Indicate ‘Yes’, if the patient has taken an immunosuppressant agent in the 14 days prior to this most recent admission / presentation

SNOMED

69431002, Medicinal product acting as immunosuppressant (product)|

CL942512, Immunosuppressant agent

risk_factor_comor

1

1

1

1

1

1

1

1

presentation

MEDICATION PRIOR TO THIS ADMISSION / PRESENTATION

drug14_immunusupp_type

multi_list

Immunosuppressant agents (not corticosteroids)

drugs_Immunosuppressants

[drug14_immunusupp]=’1’

This refers to a patient who is known to have taken prescribed medications that are known to have an immunosuppressing effect (excluding steroids/corticosteroids). Topical preparations should not be recorded.

Select the immunosuppressant(s) prescribed or taken by the patient in the 14 days prior to this most recent admission / presentation

SNOMED

69431002, Medicinal product acting as immunosuppressant (product)|

CL942512, Immunosuppressant agent

risk_factor_comor

1

1

1

1

1

1

1

1

presentation

MEDICATION PRIOR TO THIS ADMISSION / PRESENTATION

drug14_antibiotic

radio

Antibiotics

1, Yes | 0, No | 99, Unknown

Antibiotics refers to any agent(s) that selectively target bacteria. Topical preparations should not be recorded.

Indicate ‘Yes’, if the patient has taken an antibiotic in the 14 days prior to this most recent admission / presentation

SNOMED

346325008, Medicinal product acting as antibacterial agent (product)|

C0279516, Antibacterial

1

1

1

1

1

1

1

1

presentation

MEDICATION PRIOR TO THIS ADMISSION / PRESENTATION

drug14_antibiotic_type

multi_list

Antibiotics

drugs_Antibiotics

[drug14_antibiotic]=’1’

Antibiotics refers to any agent(s) that selectively target bacteria. Topical preparations should not be recorded.

Select the antibiotic(s) prescribed or taken by the patient in the 14 days prior to this most recent admission / presentation

SNOMED

346325008, Medicinal product acting as antibacterial agent (product)|

C0279516, Antibacterial

1

1

1

1

1

1

1

1

presentation

MEDICATION PRIOR TO THIS ADMISSION / PRESENTATION

drug14_nsaid

radio

NSAIDs

1, Yes | 0, No | 99, Unknown

Non-steroidal anti-inflammatory drugs or NSAIDS refers to any agent that is not a corticosteroid and has potential anti-inflammatory, analgesic, antipyretic and anti-platelet activities. Most nonsteroidal anti-inflammatory drugs (NSAIDs) act by inhibiting the conversion of arachidonic acid to the precursors of prostaglandin and thromboxane by cyclooxygenase enzymes. Topical preparations should not be recorded.

Indicate ‘Yes’, if the patient has taken an NSAID in the 14 days prior to this most recent admission / presentation

16403005 |Non-steroidal anti-inflammatory agent (product)|

C0003211, Nonsteroidal Antiinflammatory Drug

1

1

1

1

1

1

presentation

MEDICATION PRIOR TO THIS ADMISSION / PRESENTATION

drug14_nsaid_type

multi_list

NSAIDs

drugs_nsaids

[drug14_nsaid]=’1’

Non-steroidal anti-inflammatory drugs or NSAIDS refers to any agent that is not a corticosteroid and has potential anti-inflammatory, analgesic, antipyretic and anti-platelet activities. Most nonsteroidal anti-inflammatory drugs (NSAIDs) act by inhibiting the conversion of arachidonic acid to the precursors of prostaglandin and thromboxane by cyclooxygenase enzymes. Topical preparations should not be recorded.

Indicate ‘Yes’, if the patient has taken an NSAID in the 14 days prior to this most recent admission / presentation

16403005 |Non-steroidal anti-inflammatory agent (product)|

C0003211, Nonsteroidal Antiinflammatory Drug

1

1

1

1

1

1

presentation

MEDICATION PRIOR TO THIS ADMISSION / PRESENTATION

drug14_nsaid_dose

number

total NSAID dose mg/day

number

[drug14_nsaid]=’1’

1

presentation

MEDICATION PRIOR TO THIS ADMISSION / PRESENTATION

drug14_nsaid_dur

number

Duration of NSAID use (days)

number

[drug14_nsaid]=’1’

1

presentation

MEDICATION PRIOR TO THIS ADMISSION / PRESENTATION

drug14_analg

radio

Analgesics/antipyretics (non-NSAID)

1, Yes | 0, No | 99, Unknown

1

presentation

MEDICATION PRIOR TO THIS ADMISSION / PRESENTATION

drug14_analg_type

checkbox

Select Analgesics/antipyretics (non-NSAID)

1, Paracetamol (Acetaminophen) | 2, Metamizole (Dipyrone) | 88, Other

[drug14_analg]=’1’

1

presentation

MEDICATION PRIOR TO THIS ADMISSION / PRESENTATION

drug14_analg_type_oth

text

Specify other Analgesics/antipyretics (non-NSAID)

[drug14_analg_type(88)]=’1’

1

presentation

MEDICATION PRIOR TO THIS ADMISSION / PRESENTATION

drug14_opio

radio

Opioids

1, Yes | 0, No | 99, Unknown

1

presentation

MEDICATION PRIOR TO THIS ADMISSION / PRESENTATION

drug14_dmard

radio

Disease-modifying antirheumatic drugs (DMARDs)

1, Yes | 0, No | 99, Unknown

1

presentation

MEDICATION PRIOR TO THIS ADMISSION / PRESENTATION

drug14_dmard_type

checkbox

Disease-modifying antirheumatic drugs (DMARDs)

1, Methotrexate | 2, Sulfasalazine | 3, Hydroxychloroquine | 4, Leflunomide | 5, Azathioprine | 6, TNF inhibitors (e.g., adalimumab, infliximab, etanercept) | 7, IL-6 inhibitors (e.g., tocilizumab) | 8, B-cell inhibitors (e.g., rituximab) | 9, T-cell co-stimulation inhibitors (e.g., abatacept) | 88, Other

[drug14_dmard]=’1’

1

presentation

MEDICATION PRIOR TO THIS ADMISSION / PRESENTATION

drug14_anticoagul

radio

Anticoagulant

1, Yes | 0, No | 99, Unknown

An anticoagulant refers to any agent capable of preventing blood clot formation, or platelet aggregation. This includes agents such as heparin, warfarin, aspirin, clopidogrel, and subcutaneously administered anticoagulants, among many others. Topical preparations are not included.

Indicate ‘Yes’, if the patient has taken an anticoagulant in the 7 days prior to this most recent admission / presentation.

SNOMED

81839001 |Medicinal product acting as anticoagulant agent (product)|

C0003280, Anticoagulant agent

1

1

1

presentation

MEDICATION PRIOR TO THIS ADMISSION / PRESENTATION

drug14_anticoagul_type

multi_list

Anticoagulant

drugs_Anticoagulant

[drug14_anticoagul]=’1’

An anticoagulant refers to any agent capable of preventing blood clot formation, or platelet aggregation. This includes agents such as heparin, warfarin, aspirin, clopidogrel, and subcutaneously administered anticoagulants, among many others. Topical preparations are not included.

Select the analgesic(s) prescribed or taken by the patient in the 14 days prior to this most recent admission / presentation

SNOMED

81839001 |Medicinal product acting as anticoagulant agent (product)|

C0003280, Anticoagulant agent

1

1

1

presentation

MEDICATION PRIOR TO THIS ADMISSION / PRESENTATION

drug14_ivfluid

radio

Intravenous (parenteral) fluids

1, Yes | 0, No | 99, Unknown

Intravenous (IV) or parenteral fluids are prescribed as a replacement of fluid, electrolytes, calories, vitamins, and other nutritional substances. Intravenous fluids may be used for rehydration, maintenance requirements or resuscitation.

Indicate ‘Yes’ if the patient received intravenous fluids in the 7 days prior to this most recent admission / presentation.

SNOMED

354078009 |Intravenous fluids and electrolytes (product)|

CL524079, IV fluid

1

1

presentation

MEDICATION PRIOR TO THIS ADMISSION / PRESENTATION

drug14_ivfluid_type

multi_list

Intravenous fluid type

drugs_IVfluids

[drug14_ivfluid] = ‘1’

This refers to the type of parenteral or intravenous (IV) fluid is prescribed as a replacement of fluid, electrolytes, calories, vitamins, and other nutritional substances. Intravenous fluids may be crystalloids (commonly including 0.9% Sodium Chloride (Normal Saline), Lactated Ringer(USP), 0.45% Sodium Chloride (Half-normal saline), 0.45% normal saline + 4% Glucose (Half-normal saline with dextrose), 0.18%-0.3% Sodium Chloride + 4% Glucose (Hypotonic saline with dextrose), 5% Glucose (Dextrose 5% in Water), Ringeracetate or Plasmalyte) or colloids (commonly including gelatins, starches or albumin).

Select the intravenous fluid(s) prescribed or taken by the patient in the 14 days prior to this most recent admission / presentation

SNOMED

1

1

presentation

MEDICATION PRIOR TO THIS ADMISSION / PRESENTATION

drug14_ivfluid_vol

number

Total intravenous fluid volume in the previous 24 hours (mL)

number

0

3000

[drug14_ivfluid] = ‘1’

Parenteral or intravenous (IV) fluid is prescribed as a replacement of fluid, electrolytes, calories, vitamins, and other nutritional substances. Intravenous fluids (crystalloids and colloids) may be used for rehydration, maintenance requirements or resuscitation.

Specify the total volume of the intravenous fluids (crystalloids and colloids) received by the patient over the previous 24 hours. Record the volume in millilitres (mL).

1

1

presentation

MEDICATION PRIOR TO THIS ADMISSION / PRESENTATION

drug14_ivfluid_reas

checkbox

Indication / reason

1, Shock | 2, High/rising haematocrit | 3, Anorexia | 4, Persistent vomiting | 88, Other

[drug14_ivfluid] = ‘1’

This refers to the indication for intravenous fluids. Shock refers to circulatory failure, causing inadequate oxygen delivery to meet cellular metabolic needs. It is characterised by any two of the following: evidence of hypoperfusion (e.g. slow capillary refill, cold skin, and rapid and weak pulse), narrow pulse pressure (less than or equal to 20mmHg), hypotension for age, and tachycardia.

Indicate the indication for intravenous fluids.

SNOMED

27942005, Shock (disorder)

C0036974, Shock

1

presentation

MEDICATION PRIOR TO THIS ADMISSION / PRESENTATION

drug14_ivfluid_reas_oth

text

Specify other reason

[drug14_ivfluid_reas(88)]=’1’

This refers to the indication for intravenous fluids. Shock refers to circulatory failure, causing inadequate oxygen delivery to meet cellular metabolic needs. It is characterised by any two of the following: evidence of hypoperfusion (e.g. slow capillary refill, cold skin, and rapid and weak pulse), narrow pulse pressure (less than or equal to 20mmHg), hypotension for age, and tachycardia.

If ‘Other’, write the indication for intravenous fluids.

presentation

MEDICATION PRIOR TO THIS ADMISSION / PRESENTATION

drug14_antihypertensive

radio

Antihypertensives

1, Yes | 0, No | 99, Unknown

This refers to any substance used in the treatment of acute or chronic hypertension regardless of pharmacological mechanism. Examples include: ACE Inhibitors (Lisinopril (Zestril), Enalapril (Vasotec), Ramipril (Altace), Captopril); Angiotensin Receptor Blockers ((Losartan (Cozaar), Valsartan (Diovan), Irbesartan (Avapro), Olmesartan (Benicar)); Beta-Blockers (Metoprolol (Lopressor), Carvedilol (Coreg), Bisoprolol, Atenolol); Calcium Channel Blockers (Amlodipine (Norvasc), Diltiazem (Cardizem), Verapamil); Diuretics (Furosemide (Lasix), Spironolactone (Aldactone), Hydrochlorothiazide (HCTZ))

Indicate ‘Yes’, if the patient has taken this medication in the 14 days prior to this most recent admission / presentation

SNOMED

372586001, Hypotensive agent (substance)

1

presentation

MEDICATION PRIOR TO THIS ADMISSION / PRESENTATION

drug14_antidiabetic

radio

Antidiabetic medications

1, Yes | 0, No | 99, Unknown

This refers to any substance used to reduce hyperglycemia or treat disorders associated with diabetes. Examples include: Metformin (Glucophage); SGLT2 Inhibitors (Empagliflozin (Jardiance), Dapagliflozin (Farxiga), Canagliflozin (Invokana)); DPP-4 Inhibitors (Sitagliptin (Januvia), Linagliptin (Tradjenta), Saxagliptin (Onglyza)); GLP-1 Receptor Agonists (Liraglutide (Victoza), Semaglutide (Ozempic), Dulaglutide (Trulicity)); Insulins (Glargine (Lantus), Aspart (NovoLog), Lispro (Humalog), Detemir (Levemir))

Indicate ‘Yes’, if the patient has taken this medication in the 14 days prior to this most recent admission / presentation

1

presentation

MEDICATION PRIOR TO THIS ADMISSION / PRESENTATION

drug14_lipidlowering

radio

Lipid-lowering drugs

1, Yes | 0, No | 99, Unknown

This refers to any substance used to lower the levels of certain lipids in the blood in the treatment of hyperlipidaemias. Examples include: Statins (Atorvastatin (Lipitor), Rosuvastatin (Crestor), Simvastatin (Zocor), Pravastatin (Pravachol)); Ezetimibe (Zetia)

Indicate ‘Yes’, if the patient has taken this medication in the 14 days prior to this most recent admission / presentation

SNOMED

373267003, Antilipemic agent (substance)

1

presentation

MEDICATION PRIOR TO THIS ADMISSION / PRESENTATION

drug14_antireflux

radio

Anti-reflux or other GI medications

1, Yes | 0, No | 99, Unknown

This refers to any substance used in the treatment gastric reflux by preventing the backward flow of stomach acid contents into the esophagus, or other drugs taken for ailments of the gastrointestinal system. Examples include: Proton Pump Inhibitors (Omeprazole (Prilosec), Pantoprazole (Protonix), Esomeprazole (Nexium), Lansoprazole (Prevacid)); H2-Receptor Antagonists (Ranitidine (Zantac), Famotidine (Pepcid))

Indicate ‘Yes’, if the patient has taken this medication in the 14 days prior to this most recent admission / presentation

1

presentation

MEDICATION PRIOR TO THIS ADMISSION / PRESENTATION

drug14_antidepress

radio

Antidepressants and Anxiolytics

1, Yes | 0, No | 99, Unknown

Antidepressants refers to mood-stimulating drugs used primarily in the treatment of affective disorders and related conditions. Anxiolytics refers to drugs used to treat anxiety disorders. Examples include: Selective Serotonin Reuptake Inhibitors (Sertraline (Zoloft), Citalopram (Celexa), Fluoxetine (Prozac), Escitalopram (Lexapro)); Serotonin-Norepinephrine Reuptake Inhibitors (Venlafaxine (Effexor), Duloxetine (Cymbalta)); Benzodiazepines (Lorazepam (Ativan), Diazepam (Valium), Alprazolam (Xanax))

Indicate ‘Yes’, if the patient has taken this medication in the 14 days prior to this most recent admission / presentation

SNOMED

372720008, Antidepressant (substance)

1

1

presentation

MEDICATION PRIOR TO THIS ADMISSION / PRESENTATION

drug14_antiepileptic

radio

Antiepileptics

1, Yes | 0, No | 99, Unknown

This refers to any substance used stop, prevent, or control seizures (convulsions). Examples include: Levetiracetam (Keppra), Valproate (Depakote), Carbamazepine (Tegretol), Lamotrigine (Lamictal).

Indicate ‘Yes’, if the patient has taken this medication in the 14 days prior to this most recent admission / presentation

1

1

presentation

MEDICATION PRIOR TO THIS ADMISSION / PRESENTATION

drug14_herb

radio

Herbal or traditional treatment

1, Yes | 0, No | 99, Unknown

Herbal or traditional treatment refers to herbs, herbal materials, herbal preparations and finished herbal products, that contain as active ingredients parts of plants, and other knowledge, skills, and practices based on the theories, beliefs, and experiences indigenous to different cultures that are used to treat physical or mental illness.

Indicate ‘Yes’, if the patient has taken a ‘Herbal or traditional treatment in the 14 days prior to this most recent admission / presentation

SNOMED

349365008, Herbal medicine (product)

C2240391, Herbal medicine (product)

1

1

presentation

MEDICATION PRIOR TO THIS ADMISSION / PRESENTATION

drug14_herbreas

text

Specify active ingredient in herbal or traditional treatment

[drug14_herb]=’1’

This refers to the pharmaceutically active component(s) of a preparation of herbal or traditional medication(s).

If ‘Yes’, specify the pharmaceutically active component(s) of a preparation of herbal or traditional medication(s).

1

1

presentation

MEDICATION PRIOR TO THIS ADMISSION / PRESENTATION

drug14_hivprep

radio

HIV PrEP / PEP

1, Yes | 0, No | 99, Unknown

This refers to pre-exposure prophylaxis (PrEP) and post-exposure prophylaxis (PEP) to prevent HIV.

Indicate ‘Yes’, if the patient received anti-retroviral therapy, for the purposes of PrEP and PEP to prevent HIV, in the 14 days prior to this most recent admission / presentation.

SNOMED

1287783000, Administration of human immunodeficiency virus pre-exposure prophylaxis (procedure) | 235921000112100, Administration of human immunodeficiency virus post-exposure prophylaxis (procedure)

1

1

presentation

MEDICATION PRIOR TO THIS ADMISSION / PRESENTATION

drug14_chemo

radio

Cancer chemotherapy

1, Yes | 0, No | 99, Unknown

This refers to a history of exposure to cancer chemotherapy in the 14 days prior to this most recent admission / presentation.

Indicate ‘Yes’ if the patients has a history of exposure to cancer chemotherapy in the 14 days prior to this most recent admission / presentation.

presentation

MEDICATION PRIOR TO THIS ADMISSION / PRESENTATION

drug14_unlisted

radio

Other pathogen-targeted medications

1, Yes | 0, No | 99, Unknown

This refers to other pathogen-targeted medication, not listed above.

Indicate ‘Yes’, if pathogen-targeted medications (other than those specified above) have been taken in the 14 days prior to this most recent admission / presentation.

1

1

1

1

1

1

1

1

presentation

MEDICATION PRIOR TO THIS ADMISSION / PRESENTATION

drug14_unlisted_type

text

Specify other pathogen-targeted medications

[drug14_unlisted]=’1’

This refers to other pathogen-targeted medication, not listed above.

Indicate ‘Yes’, if pathogen-targeted medications (other than those specified above) have been taken in the 14 days prior to this most recent admission / presentation.

1

1

1

1

1

1

1

1

presentation

VACCINATION

vacci_covid19

radio

Vaccinated for COVID-19 (ever)

1, Yes | 0, No | 99, Unknown

Ever received a vaccine targeted against SARS-Cov-2. Examples include Spikevax (Moderna), Comirnaty (Pfizer/BioNTech), Nuvaxovid (Novavax), Vaxzevria (AstraZeneca/Oxford), Janssen COVID-19 Vaccine (Johnson & Johnson), Valneva (Valneva).

Indicate ‘Yes’, if the patient has ever received a vaccine targetted against SARS-Cov-2

risk_factor_comor

1

1

1

presentation

VACCINATION

vacci_covid19_date1

date_dmy

Date of first COVID-19 vaccine

date_dmy

today

[vacci_covid19] = ‘1’

This refers to the date on which the first dose of COVID-19 vaccine was received in the format DD/MM/YYYY. If precise date unknown, estimate.

Enter the date of first COVID-19 vaccine. If the precise date is unknown, enter an estimate. (Use the format DD/MM/YYYY)

1

presentation

VACCINATION

vacci_covid19_type1

radio

Type of first COVID-19 vaccine

1, Pfizer/BioNTech | 2, AstraZeneca/University of Oxford (Covishield in India) | 3, Moderna | 4, Novavax |5, Janssen (Johnson & Johnson) | 6, Sinopharm | 7, Sinovac | 8, Sputnik V | 9, Covaxin | 10, CanSinoBIO | 99, Unknown | 0, Other, please specify

[vacci_covid19] = ‘1’

Refers to the type of the first COVID-19 vaccine the patient received.

Select the type of first COVID-19 vaccine.

1

presentation

VACCINATION

vacci_covid19_type1_oth

text

Specify other type of COVID-19 vaccine

[vacci_covid19_type1] = ‘0’

Refers to the type of the first COVID-19 vaccine the patient received.

If ‘Other’, specify the type of COVID-19 vaccine.

1

presentation

VACCINATION

vacci_covid19_date2

date_dmy

Date of second COVID-19 vaccine

date_dmy

today

[vacci_covid19] = ‘1’

This refers to the date on which the second dose of COVID-19 vaccine was received in the format DD/MM/YYYY. If precise date unknown, estimate.

Enter the date of second COVID-19 vaccine. If the precise date is unknown, enter an estimate. (Use the format DD/MM/YYYY)

1

presentation

VACCINATION

vacci_covid19_type2

radio

Type of second COVID-19 vaccine

1, Pfizer/BioNTech | 2, AstraZeneca/University of Oxford (Covishield in India) | 3, Moderna | 4, Novavax |5, Janssen (Johnson & Johnson) | 6, Sinopharm | 7, Sinovac | 8, Sputnik V | 9, Covaxin | 10, CanSinoBIO | 99, Unknown | 0, Other, please specify

[vacci_covid19] = ‘1’

Refers to the type of the second COVID-19 vaccine the patient received.

Select the type of second COVID-19 vaccine.

1

presentation

VACCINATION

vacci_covid19_type2_oth

text

Specify other type of COVID-19 vaccine

[vacci_covid19_type2] = ‘0’

Refers to the type of the second COVID-19 vaccine the patient received.

If ‘Other’, specify the type of COVID-19 vaccine.

1

presentation

VACCINATION

vacci_covid19_date3

date_dmy

Date of third COVID-19 vaccine

date_dmy

today

[vacci_covid19] = ‘1’

This refers to the date on which the third dose of COVID-19 vaccine was received in the format DD/MM/YYYY. If precise date unknown, estimate.

Enter the date of third COVID-19 vaccine. If the precise date is unknown, enter an estimate. (Use the format DD/MM/YYYY)

1

presentation

VACCINATION

vacci_covid19_type3

radio

Type of third COVID-19 vaccine

1, Pfizer/BioNTech | 2, AstraZeneca/University of Oxford (Covishield in India) | 3, Moderna | 4, Novavax |5, Janssen (Johnson & Johnson) | 6, Sinopharm | 7, Sinovac | 8, Sputnik V | 9, Covaxin | 10, CanSinoBIO | 99, Unknown | 0, Other, please specify

[vacci_covid19] = ‘1’

Refers to the type of the third COVID-19 vaccine the patient received.

Select the type of third COVID-19 vaccine.

1

presentation

VACCINATION

vacci_covid19_type3_oth

text

Specify other type of COVID-19 vaccine

[vacci_covid19_type3] = ‘0’

Refers to the type of the third COVID-19 vaccine the patient received.

If ‘Other’, specify the type of COVID-19 vaccine.

1

presentation

VACCINATION

vacci_covid19_lastdate

date_dmy

Date of most recent COVID-19 vaccine

date_dmy

today

[vacci_covid19] = ‘1’

This refers to the date on which the most recent COVID-19 vaccine was received in the format DD/MM/YYYY. If precise date unknown, estimate.

Enter the date of most recent COVID-19 vaccine. If the precise date is unknown, enter an estimate. (Use the format DD/MM/YYYY)

1

1

presentation

VACCINATION

vacci_covid19_lasttype

radio

Type of most recent COVID-19 vaccine

1, Pfizer/BioNTech | 2, AstraZeneca/University of Oxford (Covishield in India) | 3, Moderna | 4, Novavax |5, Janssen (Johnson & Johnson) | 6, Sinopharm | 7, Sinovac | 8, Sputnik V | 9, Covaxin | 10, CanSinoBIO | 99, Unknown | 88, Other

[vacci_covid19] = ‘1’

Refers to the type of the most recent COVID-19 vaccine the patient received.

Select the type of most recent COVID-19 vaccine.

1

1

presentation

VACCINATION

vacci_covid19_lasttype_oth

text

Specify other type of COVID-19 vaccine

[vacci_covid19_lasttype] = ‘88’

Refers to the type of the most recent COVID-19 vaccine the patient received.

If ‘Other’, specify the type of COVID-19 vaccine.

1

1

presentation

VACCINATION

vacci_influenza

radio

Vaccinated for seasonal influenza (ever)

1, Yes | 0, No | 99, Unknown

Ever received a vaccine targeting seasonal influenza.

Indicate ‘Yes’, if the patient has ever received a seasonal influenza vaccine.

risk_factor_comor

1

1

1

1

presentation

VACCINATION

vacci_influenza_date

date_dmy

Date of most recent seasonal influenza vaccine

date_dmy

today

[vacci_influenza] = ‘1’

This refers to the date of the most recent seasonal influenza vaccine

Enter the date of most recent seasonal influenza vaccine. If the precise date is unknown, enter an estimate. (Use the format DD/MM/YYYY)

risk_factor_comor

1

1

1

presentation

VACCINATION

vacci_influenza_type

radio

Type of last influenza vaccine

1, Inactivated Influenza Vaccine (IIV) | 2, Live Attenuated Influenza Vaccine (LAIV) | 3, Recombinant Influenza Vaccine (RIV) | 4, Cell-Based Influenza Vaccine (ccIIV) | 5, Egg-Based Influenza Vaccine | 6, mRNA-Based Influenza Vaccines (Emerging Technology) | 99, Unknown | 88, Other

[vacci_influenza] = ‘1’

This refers to the type of the most recent seasonal influenza vaccine

Select the most appropriate option which represents the type of most recent seasonal influenza vaccine.

1

presentation

VACCINATION

vacci_influenza_type_oth

text

Specify type of Influenza vaccine

[vacci_influenza_type] = ‘88’

This refers to the type of the most recent seasonal influenza vaccine

If ‘Other’, specify the type of most recent seasonal infuenza vaccine.

1

presentation

VACCINATION

vacci_aviinflu

radio

Vaccinated for avian influenza

1, Yes | 0, No | 99, Unknown

Ever received a vaccine targeting avian influenza.

Indicate ‘Yes’, if the patient has ever received an avian influenza vaccine.

risk_factor_comor

1

1

1

presentation

VACCINATION

vacci_aviinflu_date

date_dmy

Date of most recent avian influenza vaccine

date_dmy

today

[vacci_aviinflu] = ‘1’

This refers to the date of the most recent avian influenza vaccine

Enter the date of most recent avian influenza vaccine. If the precise date is unknown, enter an estimate. (Use the format DD/MM/YYYY)

risk_factor_comor

1

1

1

presentation

VACCINATION

vacci_aviinflu_type

radio

Type of most recent avian influenza vaccine

1, Quadrivalent, recombinant | 2, Quadrivalent, adjuvanted inactivated | 3, Quadrivalent, high dose | 4, Quadrivalent, cell-based | 5, Influenza Tetra MYL | 6, Trivalent, recombinant | 7, Trivalent, high dose | 8, Trivalent, adjuvant inactivated | 9, Trivalent, intranasal | 10, H5N1 (Audenz, Aflunov) | 99, Unknown | 88, Other

[vacci_aviinflu] = ‘1’

This refers to the type of the most recent avian influenza vaccine

Select the most appropriate option which represents the type of most recent avian influenza vaccine.

1

presentation

VACCINATION

vacci_aviinflu_type_oth

text

Specify type of avian Influenza vaccine

[vacci_aviinflu_type]=’88’

This refers to the type of the most recent avian influenza vaccine

If ‘Other’, specify the type of most recent avian infuenza vaccine.

1

presentation

VACCINATION

vacci_rsv

radio

Vaccinated for Respiratory Syncytial Virus (RSV)

1, Yes | 0, No | 99, Unknown

Ever received a vaccine targeting Respiratory Syncytial Virus.

Indicate ‘Yes’, if the patient has ever received a RSV vaccine.

risk_factor_comor

1

1

1

presentation

VACCINATION

vacci_rsv_date

date_dmy

Date of most recent Respiratory Syncytial Virus (RSV) vaccine

date_dmy

today

[vacci_rsv] = ‘1’

This refers to the date of the most recent avian influenza vaccine

Enter the date of most recent RSV vaccine. If the precise date is unknown, enter an estimate. (Use the format DD/MM/YYYY)

risk_factor_comor

1

1

1

presentation

VACCINATION

vacci_rsv_type

radio

Type of most recent Respiratory Syncytial Virus (RSV) vaccine

1, Abrysvo (Pfizer) | 2, Arexvy (GlaxoSmithKline) | 3, mResvia (Moderna) | 99, Unknown | 88, Other

[vacci_rsv] = ‘1’

This refers to the type of the most recent Respiratory Syncytial Virus (RSV) influenza vaccine

Select the most appropriate option which represents the type of most recent Respiratory Syncytial Virus (RSV) influenza vaccine.

1

presentation

VACCINATION

vacci_rsv_type_oth

text

Specify type of Respiratory Syncytial Virus (RSV) vaccine

[vacci_rsv_type]=’88’

This refers to the type of the most recent Respiratory Syncytial Virus (RSV) influenza vaccine

If ‘Other’, specify the type of most recent Respiratory Syncytial Virus (RSV) infuenza vaccine.

1

presentation

VACCINATION

vacci_pneumococo

radio

Vaccinated for pneumococcal disease

1, Yes | 0, No | 99, Unknown

Ever received a vaccine targeting Pneumococcus (Streptococcus pneumoniae).

Indicate ‘Yes’, if the patient has ever received a Pneumococcal vaccine.

1

presentation

VACCINATION

vacci_pneumococo_date

date_dmy

Date of most recent pneumococcal disease vaccine

date_dmy

today

[vacci_pneumococo]=’1’

This refers to the date of the most recent Pneumococcal vaccine

Enter the date of most recent pneumococcal vaccine. If the precise date is unknown, enter an estimate. (Use the format DD/MM/YYYY)

1

presentation

VACCINATION

vacci_dengue

radio

Vaccinated for dengue

1, YES-once | 2, YES-twice | 3, YES-thrice | 0, No | 99, Unknown

This refers to whether the patient has ever received the dengue vaccine prior to this illness episode and the number of previous dengue vaccines received.

Select the most appropriate option that represents whether the patient has ever received the dengue vaccine prior to this illness episode and the number of previous dengue vaccines received.

SNOMED

827179001, Administration of vaccine product containing only Dengue virus antigen (procedure)

C5231315, Administration of dengue vaccine

risk_factor_comor

1

1

presentation

VACCINATION

vacci_dengue_date1

date_dmy

Date of first dengue vaccine

date_dmy

today

[vacci_dengue]=’1’ or [vacci_dengue]=’2’ or [vacci_dengue]=’3’

This refers to the date on which the first dose of dengue vaccine was received in the format DD/MM/YYYY. If precise date unknown, estimate.

Enter the date of first dengue vaccine. If the precise date is unknown, enter an estimate. (Use the format DD/MM/YYYY)

1

1

presentation

VACCINATION

vacci_dengue_type1

radio

Type of first dengue vaccine

1, CYD-TVD (Dengvaxia) | 2, TAK-003 (QDENGA)

[vacci_dengue]=’1’ or [vacci_dengue]=’2’ or [vacci_dengue]=’3’

Refers to the type of the first dengue vaccine the patient received.

Select the most appropriate option that represents the type of the first dengue vaccine the patient received.

C5196214, Dengvaxia |

1

1

presentation

VACCINATION

vacci_dengue_date2

date_dmy

Date of second dengue vaccine

date_dmy

today

[vacci_dengue]=’2’ or [vacci_dengue]=’3’

This refers to the date on which the second dose of dengue vaccine was received in the format DD/MM/YYYY. If precise date unknown, estimate.

Enter the date of second dengue vaccine. If the precise date is unknown, enter an estimate. (Use the format DD/MM/YYYY)

1

1

presentation

VACCINATION

vacci_dengue_type2

radio

Type of second dengue vaccine

1, CYD-TVD (Dengvaxia) | 2, TAK-003 (QDENGA)

[vacci_dengue]=’2’ or [vacci_dengue]=’3’

Refers to the type of the second dengue vaccine the patient received.

Select the most appropriate option that represents the type of the second dengue vaccine the patient received.

C5196214, Dengvaxia |

1

1

presentation

VACCINATION

vacci_dengue_date3

date_dmy

Date of third dengue vaccine

date_dmy

today

[vacci_dengue]=’3’

This refers to the date on which the third dose of dengue vaccine was received in the format DD/MM/YYYY. If precise date unknown, estimate.

Enter the date of third dengue vaccine. If the precise date is unknown, enter an estimate. (Use the format DD/MM/YYYY)

1

1

presentation

VACCINATION

vacci_chick

radio

Vaccinated for chikungunya (ever)

1, Yes | 0, No | 99, Unknown

1

presentation

VACCINATION

vacci_chick_type

radio

Type of CHIKV vaccine

1, IXCHIQ | 2, VIMKUNYA| 88, Other

[vacci_chick]=’1’

1

presentation

VACCINATION

vacci_chick_type_oth

text

Specify other Type of CHIKV vaccine

[vacci_chick_type]=’88’

1

presentation

VACCINATION

vacci_chick_date

date_dmy

Date of CHIKV vaccine

date_dmy

[vacci_chick]=’1’

1

presentation

VACCINATION

vacci_dengue_type3

radio

Type of third dengue vaccine

1, CYD-TVD (Dengvaxia) | 2, TAK-003 (QDENGA)

[vacci_dengue]=’3’

Refers to the type of the third dengue vaccine the patient received.

Select the most appropriate option that represents the type of the third dengue vaccine the patient received.

C5196214, Dengvaxia |

1

1

presentation

VACCINATION

vacci_spox80

radio

Received smallpox vaccine prior to 1980?

1, Yes | 0, No | 99, Unknown

This refers to receiving a smallpox vaccine prior to 1980 and thus unrelated to the current event.

Indicate ‘Yes’, if the patient recieved a smallpox vaccine prior to 1980.

1

1

presentation

VACCINATION

vacci_spox80_year

number

Year vaccinated (estimate if uncertain)

number

1980

[vacci_spox80]=’1’

This refers to receiving a smallpox vaccine prior to 1980 and thus unrelated to the current event.

Write the year in which the patient received the smallpox vaccine. Estimate if uncertain. Note it must not exceed 1980. Leave response empty if year is unknown.

1

1

presentation

VACCINATION

vacci_spox80_scar

radio

Is a smallpox vaccination scar visible (usually on the upper arm if present)?

1, Yes | 0, No | 99, Unknown

[vacci_spox80]=’1’

This refers to a scar at the site of smallpox vaccination (usually on the upper arm if present)) which is generally round, may have irregular edges and appear lower than the skin around it.

Indicate ‘Yes’, if the patient has a visible smallpox vaccine scar.

1

1

presentation

VACCINATION

vacci_mpox

radio

Received smallpox or mpox vaccination after 1980?

1, Yes | 0, No | 99, Unknown

This refers to any smallpox or mpox vaccination after 1980.

Indicate ‘Yes’, if the patient received the smallpox vaccination after 1980.

SNOMED

229881000001106, Smallpox vaccine (product) |

C0037355, smallpox vaccine | C5703650, Mpox Vaccine

1

1

presentation

VACCINATION

vacci_mpox_number

number

Number of mpox or smallpox vaccines received

number

1

4

[vacci_mpox]=’1’

This refers to the number of Mpox or smallpox vaccines received.

Write the number of Mpox or smallpox vaccines received.

1

1

presentation

VACCINATION

vacci_mpox_type

checkbox

Mpox or smallpox vaccine type

1, Imvanex/Imvamune/Jyneos (MVA-BN) | 2, ACAM2000 | 3, LC16m8 | 99, Unknown | 88, Other

[vacci_mpox]=’1’

This refers to the type of Mpox or smallpox vaccine.

Select the option(s) corresponding to the vaccine(s) received. If ‘Other’, Specify the other vaccine(s) below.

1

1

presentation

VACCINATION

vacci_mpox_type_oth

text

Name of other mpox or smallpox vaccine

[vacci_mpox_type(88)]=’1’

This refers to the type of Mpox or smallpox vaccine.

If ‘Other’, Write the name(s) of the other smallpox/mpox vaccine(s).

1

1

presentation

VACCINATION

vacci_mpox_date1

date_dmy

Date of first mpox or smallpox vaccine

date_dmy

today

[vacci_mpox_number] >= 1

This refers to the first mpox of smallpox vaccine.

Enter the date of first mpox or smallpox vaccine. If the precise date is unknown, enter an estimate. (Use the format DD/MM/YYYY)

1

1

presentation

VACCINATION

vacci_mpox_route1

radio

Route of administration for first mpox or smallpox vaccine

1, Intramuscular | 2, Subcutaneous | 3, Intradermal | 99, Unknown | 88, Other

[vacci_mpox_number] >= 1

presentation

VACCINATION

vacci_mpox_route1_oth

text

Please specify other route

[vacci_mpox_route1] = ‘88’

presentation

VACCINATION

vacci_mpox_date2

date_dmy

Date of second mpox or smallpox vaccine

date_dmy

today

[vacci_mpox_number] >= 2

This refers to the second mpox of smallpox vaccine.

Enter the date of second mpox or smallpox vaccine. If the precise date is unknown, enter an estimate. (Use the format DD/MM/YYYY)

1

1

presentation

VACCINATION

vacci_mpox_route2

radio

Route of administration for second mpox or smallpox vaccine

1, Intramuscular | 2, Subcutaneous | 3, Intradermal | 99, Unknown | 88, Other

[vacci_mpox_number] >= 2

presentation

VACCINATION

vacci_mpox_route2_oth

text

Please specify other route

[vacci_mpox_route2] = ‘88’

presentation

VACCINATION

vacci_mpox_date3

date_dmy

Date of third mpox or smallpox vaccine

date_dmy

today

[vacci_mpox_number] >= 3

This refers to the third mpox of smallpox vaccine.

Enter the date of third mpox or smallpox vaccine. If the precise date is unknown, enter an estimate. (Use the format DD/MM/YYYY)

1

1

presentation

VACCINATION

vacci_mpox_route3

radio

Route of administration for third mpox or smallpox vaccine

1, Intramuscular | 2, Subcutaneous | 3, Intradermal | 99, Unknown | 88, Other

[vacci_mpox_number] >= 3

presentation

VACCINATION

vacci_mpox_route3_oth

text

Please specify other route

[vacci_mpox_route3] = ‘88’

presentation

VACCINATION

vacci_mpox_date4

date_dmy

Date of fourth mpox or smallpox vaccine

date_dmy

today

[vacci_mpox_number] >= 4

This refers to the fourth mpox of smallpox vaccine.

Enter the date of fourth mpox or smallpox vaccine. If the precise date is unknown, enter an estimate. (Use the format DD/MM/YYYY)

1

1

presentation

VACCINATION

vacci_mpox_route4

radio

Route of administration for fourth mpox or smallpox vaccine

1, Intramuscular | 2, Subcutaneous | 3, Intradermal | 99, Unknown | 88, Other

[vacci_mpox_number] >= 4

presentation

VACCINATION

vacci_mpox_route4_oth

text

Please specify other route

[vacci_mpox_route4] = ‘88’

presentation

VACCINATION

vacci_yellowfever

radio

Vaccinated for yellow fever

1, Yes | 0, No | 99, Unknown

Ever received a vaccine targeting Yellow Fever Virus.

Indicate ‘Yes’, if the patient has ever received a Yellow fever vaccine.

1

presentation

VACCINATION

vacci_yellowfever_date

date_dmy

Most recent yellow fever vaccination date

date_dmy

today

[vacci_yellowfever]=’1’

This refers to the date of the most recent yellow fever vaccine

Enter the date of most recent yellow fever vaccine. If the precise date is unknown, enter an estimate. (Use the format DD/MM/YYYY)

presentation

VACCINATION

vacci_hepatitisb

radio

Vaccinated for hepatitis B

1, Yes | 0, No | 99, Unknown

Ever received a vaccine targeting Hepatitis B virus.

Indicate ‘Yes’, if the patient has ever received a hepatitis B vaccine.

presentation

VACCINATION

vacci_hepatitisb_date

date_dmy

Most recent hepatitis B vaccination date

date_dmy

today

[vacci_hepatitisb]=’1’

This refers to the date of the most recent Hepatitis B virus vaccine

Enter the date of most recent Hepatitis B vaccine. If the precise date is unknown, enter an estimate. (Use the format DD/MM/YYYY)

presentation

VACCINATION

vacci_chickenpox

radio

Vaccinated for chickenpox (varicella)

1, Yes | 0, No | 99, Unknown

Ever received a vaccine targeting varicella-zoster virus.

Indicate ‘Yes’, if the patient has ever received a Yellow Chickenpox vaccine.

1

presentation

VACCINATION

vacci_chickenpox_date

date_dmy

Most recent chickenpox(varicella) vaccination date

date_dmy

today

[vacci_chickenpox]=’1’

This refers to the date of the most recent varicella-zoster virus vaccine

Enter the date of most recent chickenpox vaccine. If the precise date is unknown, enter an estimate. (Use the format DD/MM/YYYY)

presentation

VACCINATION

vacci_polio

radio

Vaccinated for polio (oral)

1, Yes | 0, No | 99, Unknown

1

presentation

VACCINATION

vacci_hib

radio

Vaccinated for Haemophilus influenzae type b (Hib)

1, Yes | 0, No | 99, Unknown

1

presentation

VACCINATION

vacci_pcv

radio

Vaccinated for Pneumococcal Conjugate (PCV)

1, Yes | 0, No | 99, Unknown

1

presentation

VACCINATION

vacci_mmr

radio

Vaccinated for Measles, Mumps, Rubella (MMR)

1, Yes | 0, No | 99, Unknown

1

presentation

VACCINATION

vacci_je

radio

Vaccinated for Japanese Encephalitis

1, Yes | 0, No | 99, Unknown

1

presentation

VACCINATION

vacci_marburg

radio

Vaccinated for Marburg virus disease

1, Yes | 0, No | 99, Unknown

Ever received a vaccine targeting Marburg virus.

Indicate ‘Yes’, if the patient has ever received a Yellow Chickenpox vaccine.

presentation

VACCINATION

vacci_marburg_date

date_dmy

Most recent Marburg virus disease vaccination date

date_dmy

today

[vacci_marburg]=’1’

This refers to the date of the most recent Marburg virus vaccine

Enter the date of most recent chickenpox vaccine. If the precise date is unknown, enter an estimate. (Use the format DD/MM/YYYY)

presentation

VACCINATION

vacci_ebola

radio

Vaccinated for Ebola virus disease

1, Yes | 0, No | 99, Unknown

Ever received a vaccine targeting Ebola virus.

Indicate ‘Yes’, if the patient has ever received a Yellow Chickenpox vaccine.

presentation

VACCINATION

vacci_ebola_date

date_dmy

Most recent Ebola virus disease vaccination date

date_dmy

today

[vacci_ebola]=’1’

This refers to the date of the most recent Ebola virus vaccine

Enter the date of most recent chickenpox vaccine. If the precise date is unknown, enter an estimate. (Use the format DD/MM/YYYY)

presentation

VACCINATION

vacci_lassa

radio

Vaccinated for Lassa fever disease

1, Yes | 0, No | 99, Unknown

Ever received a vaccine targeting Lassa fever virus.

Indicate ‘Yes’, if the patient has ever received a Yellow Chickenpox vaccine.

presentation

VACCINATION

vacci_lassa_date

date_dmy

Most recent Lassa fever disease vaccination date

date_dmy

today

[vacci_lassa]=’1’

This refers to the date of the most recent Lassa fever virus vaccine

Enter the date of most recent chickenpox vaccine. If the precise date is unknown, enter an estimate. (Use the format DD/MM/YYYY)

presentation

VACCINATION

vacci_crimean

radio

Vaccinated for Crimean-Congo haemorrhagic fever

1, Yes | 0, No | 99, Unknown

Ever received a vaccine targeting Crimean-Congo haemorrhagic fever virus.

Indicate ‘Yes’, if the patient has ever received a Yellow Chickenpox vaccine.

presentation

VACCINATION

vacci_crimean_date

date_dmy

Most recent Crimean-Congo haemorrhagic feve vaccination date

date_dmy

today

[vacci_crimean]=’1’

This refers to the date of the most recent Crimean-Congo haemorrhagic fever virus vaccine

Enter the date of most recent chickenpox vaccine. If the precise date is unknown, enter an estimate. (Use the format DD/MM/YYYY)

presentation

VACCINATION

vacci_vhf

radio

Vaccinated for Other viral haemorrhagic fever

1, Yes | 0, No | 99, Unknown

Ever received a vaccine targeting a Viral hemorragic fever virus( different from above).

Indicate ‘Yes’, if the patient has ever received a Yellow Chickenpox vaccine.

presentation

VACCINATION

vacci_vhf_spec

text

Specify Other viral haemorrhagic fever Vaccine

[vacci_vhf]=’1’

Specify the Viral hemorragic fever virus.

Indicate ‘Yes’, if the patient has ever received a Yellow Chickenpox vaccine.

presentation

VACCINATION

vacci_vhf_date

date_dmy

Most recent Other viral haemorrhagic fever vaccination date

date_dmy

today

[vacci_vhf]=’1’

This refers to the date of the most recent Viral hemorragic fever virus vaccine

Enter the date of most recent chickenpox vaccine. If the precise date is unknown, enter an estimate. (Use the format DD/MM/YYYY)

presentation

SYMPTOMS ON ADMISSION: Indicate if experienced at any time from onset of this illness to the day of presentation.

adsym_sys

descriptive

Systemic / general symptoms

Systemic/General

This refers to systemic / general / non-specific signs and symptoms

Indicate ‘Yes’, if the patient has experienced this at any time from onset of this illness to presentation.

1

1

1

1

1

1

1

1

1

presentation

SYMPTOMS ON ADMISSION: Indicate if experienced at any time from onset of this illness to the day of presentation.

adsym_fever

radio

Fever

1, Yes | 0, No | 99, Unknown

Systemic/General

This refers to sensation of elevated body temperature without formal measurement, or a measured body temperature greater or equal to 38-degrees Celsius (38°C) or 100.4-Fahrenheit (100.4°F).

Indicate ‘Yes’, if the patient experienced this at any time during the date of assessment.

SNOMED

386661006, Fever

C0015967, Fever

clinical_features

1

1

1

1

1

1

1

1

1

presentation

SYMPTOMS ON ADMISSION: Indicate if experienced at any time from onset of this illness to the day of presentation.

adsym_rigchill

radio

Chills or rigors

1, Yes | 0, No | 99, Unknown

[demog_calcage_days]>=365

Systemic/General

This refers to severe chills with violent shivering. A rigor is an episode of shaking or exaggerated shivering which can occur with a high fever.

Indicate ‘Yes’, if the patient has experienced this at any time from onset of this illness to presentation.

SNOMED

43724002, Chill (finding)_38880002 Rigor (finding)

1

1

1

1

1

1

presentation

SYMPTOMS ON ADMISSION: Indicate if experienced at any time from onset of this illness to the day of presentation.

adsym_nightsweat

radio

Night sweats

1, Yes | 0, No | 99, Unknown

[demog_calcage_days]>=365

Systemic/General

This refers to perspiration experienced nocturnally that is unrelated to environmental temperature.

Indicate ‘Yes’, if the patient experienced this at any time during the date of assessment.

42984000, Night sweats (finding)

1

presentation

SYMPTOMS ON ADMISSION: Indicate if experienced at any time from onset of this illness to the day of presentation.

adsym_coldsweat

radio

Cold sweats

1, Yes | 0, No | 99, Unknown

[demog_calcage_days]>=28

Systemic/General

This refers to sweats accompanied by sensation of feeling cold, different from sweats caused by heat or exertion.

Indicate ‘Yes’, if the patient experienced this at any time during the date of assessment.

83547004, Cold sweat (finding)

1

presentation

SYMPTOMS ON ADMISSION: Indicate if experienced at any time from onset of this illness to the day of presentation.

adsym_excesssweat

radio

Excessive sweating (hyperhidrosis)

1, Yes | 0, No | 99, Unknown

Systemic/General

This refers to excessive sweating that is not always related to fever, heat exposure or vigorous exercise.

Indicate ‘Yes’, if the patient experienced this at any time during the date of assessment.

312230002, Hyperhidrosis (disorder)

1

presentation

SYMPTOMS ON ADMISSION: Indicate if experienced at any time from onset of this illness to the day of presentation.

adsym_restlessne

radio

Restlessness

1, Yes | 0, No | 99, Unknown

Systemic/General

This refers to a state of unease, characterised by an inability to rest or relax, diffuse motor activity with limited control, nonproductive or disorganized behaviour, and subjective distress.

Indicate ‘Yes’, if the patient experienced this at any time during the date of assessment.

SNOMED

162221009, Restlessness

C3887611, Restlessness

clinical_features

1

1

1

presentation

SYMPTOMS ON ADMISSION: Indicate if experienced at any time from onset of this illness to the day of presentation.

adsym_fatigue

radio

Fatigue / malaise / lethargy

1, Yes | 0, No | 99, Unknown

[demog_calcage_days]>=365

Systemic/General

This refers to a constellation of non-specific sensations: the feeling of tiredness characterised by a lack of energy or motivation; general discomfort or uneasiness; disinterestedness, listlessness, and indifference, resulting in difficulty performing simple tasks or concentrating.

Indicate ‘Yes’, if the patient has experienced this at any time from onset of this illness to presentation.

SNOMED

84229001, Fatigue |367391008, Malaise |214264003, Lethargy

C0015672, Fatigue | C0231218, Malaise | C0023380 Lethargy

clinical_features

1

1

1

1

1

1

1

1

1

1

presentation

SYMPTOMS ON ADMISSION: Indicate if experienced at any time from onset of this illness to the day of presentation.

adsym_weak

radio

Weakness

1, Yes | 0, No | 99, Unknown

Systemic/General

This refers to a decrease in muscle strength.

Indicate ‘Yes’, if the patient has experienced this at any time from onset of this illness to presentation.

SNOMED

13791008

clinical_features

1

presentation

SYMPTOMS ON ADMISSION: Indicate if experienced at any time from onset of this illness to the day of presentation.

adsym_weight

radio

Weight loss

1, Yes | 0, No | 99, Unknown

Systemic/General

This refers to reduction in total body weight (patient-reported or objectively measured) that has occurred since the onset of this illness and has been unintentional or not attributable to active dieting, exercise or dedicated medication based weight-loss interventions.

Indicate ‘Yes’, if the patient has experienced this at any time from onset of this illness to presentation.

SNOMED

448765001 Unintentional weight loss

C2363736 Unintentional Weight loss

clinical_features

1

1

1

presentation

SYMPTOMS ON ADMISSION: Indicate if experienced at any time from onset of this illness to the day of presentation.

adsym_anosmia

radio

Loss of smell (anosmia)

1, Yes | 0, No | 99, Unknown

Systemic/General

This refers to patient reported and/or clinician-diagnosed inability of the patient to perceive odours

Indicate ‘Yes’, if the patient experienced this at any time during the date of assessment.

SNOMED

44169009, Loss of sense of smell

C0003126, Anosmia

clinical_features

1

1

1

presentation

SYMPTOMS ON ADMISSION: Indicate if experienced at any time from onset of this illness to the day of presentation.

adsym_ageusia

radio

Loss of taste (ageusia)

1, Yes | 0, No | 99, Unknown

Systemic/General

This refers to patient reported and/or clinician-diagnosed loss of taste function of the tongue.

Indicate ‘Yes’, if the patient experienced this at any time during the date of assessment.

SNOMED

36955009, Loss of taste

C2364111, Ageusia

clinical_features

1

1

1

presentation

SYMPTOMS ON ADMISSION: Indicate if experienced at any time from onset of this illness to the day of presentation.

adsym_dizzy

radio

Feeling dizzy / faint

1, Yes | 0, No | 99, Unknown

[demog_calcage_days]>=1825

Systemic/General

This refers to the subjective feeling of light-headedness or dizziness which may precede an episode of syncope or a sensation of unsteadiness, spinning or rocking.

Indicate ‘Yes’, if the patient has experienced this at any time from onset of this illness to presentation.

SNOMED

248223005, Feeling faint

C0581879, Felt faint

clinical_features

1

1

1

1

1

presentation

SYMPTOMS ON ADMISSION: Indicate if experienced at any time from onset of this illness to the day of presentation.

adsym_myalgia

radio

Muscle aches (myalgia)

1, Yes | 0, No | 99, Unknown

[demog_calcage_days]>=365

Systemic/General

This refers to pain localised to a muscle or group of muscles.

Indicate ‘Yes’, if the patient has experienced this at any time from onset of this illness to presentation.

SNOMED

68962001, Muscle pain

C0231528, Myalgia

clinical_features

1

1

1

1

1

1

1

1

1

presentation

SYMPTOMS ON ADMISSION: Indicate if experienced at any time from onset of this illness to the day of presentation.

adsym_myalgia_scal

number

Myalgia intensity (Numeric Pain Rating Scale)

number

1

10

[adsym_myalgia]=’1’

1

presentation

SYMPTOMS ON ADMISSION: Indicate if experienced at any time from onset of this illness to the day of presentation.

adsym_arthralgia

radio

Joint pain (arthralgia)

1, Yes | 0, No | 99, Unknown

[demog_calcage_days]>=365

Systemic/General

This refers to a sensation of marked discomfort or pain localised to one or more joints, including small and big joints.

Indicate ‘Yes’, if the patient has experienced this at any time from onset of this illness to presentation.

SNOMED

57676002, Joint pain

C3805780, Arthralgia

clinical_features

1

1

1

1

1

1

1

1

1

presentation

SYMPTOMS ON ADMISSION: Indicate if experienced at any time from onset of this illness to the day of presentation.

adsym_arthralgia_scal

number

Artralgia intensity (Numeric Pain Rating Scale)

number

1

10

[adsym_arthralgia]=’1’

1

presentation

SYMPTOMS ON ADMISSION: Indicate if experienced at any time from onset of this illness to the day of presentation.

adsym_arthralgia_site

checkbox

Site where joint pain occurred

1, Shoulder | 2, Elbow | 3, Wrist | 4, Small joints of hand | 5, Knee | 6, Ankle |7, Small joints of foot | 88, Other

[adsym_arthralgia]=’1’

1

presentation

SYMPTOMS ON ADMISSION: Indicate if experienced at any time from onset of this illness to the day of presentation.

adsym_arthralgia_site_shoulder

radio

How many shoulder joints are affected?

1, 1 | 2, 2 | 99, Unknown

[adsym_arthralgia_site(1)]=’1’

Systemic/General

1

presentation

SYMPTOMS ON ADMISSION: Indicate if experienced at any time from onset of this illness to the day of presentation.

adsym_arthralgia_site_elbow

radio

How many elbow joints are affected?

1, 1 | 2, 2 | 99, Unknown

[adsym_arthralgia_site(2)]=’1’

Systemic/General

1

presentation

SYMPTOMS ON ADMISSION: Indicate if experienced at any time from onset of this illness to the day of presentation.

adsym_arthralgia_site_wrist

radio

How many wrist joints are affected?

1, 1 | 2, 2 | 99, Unknown

[adsym_arthralgia_site(3)]=’1’

Systemic/General

1

presentation

SYMPTOMS ON ADMISSION: Indicate if experienced at any time from onset of this illness to the day of presentation.

adsym_arthralgia_site_knee

radio

How many knee joints are affected?

1, 1 | 2, 2 | 99, Unknown

[adsym_arthralgia_site(5)]=’1’

Systemic/General

1

presentation

SYMPTOMS ON ADMISSION: Indicate if experienced at any time from onset of this illness to the day of presentation.

adsym_arthralgia_site_ankle

radio

How many ankle joints are affected?

1, 1 | 2, 2 | 99, Unknown

[adsym_arthralgia_site(6)]=’1’

Systemic/General

1

presentation

SYMPTOMS ON ADMISSION: Indicate if experienced at any time from onset of this illness to the day of presentation.

adsym_arthralgia_site_foot

number

How many small joints of the foot are affected?

number

1

14

[adsym_arthralgia_site(7)]=’1’

Systemic/General

1

presentation

SYMPTOMS ON ADMISSION: Indicate if experienced at any time from onset of this illness to the day of presentation.

adsym_arthralgia_hand

checkbox

Small joints of hand

1, MCP (metacarpophalangeal) joint | 2, PIP (proximal interphalangeal) joint | 3, DIP (distal interphalangeal) joint | 99, Unknown

[adsym_arthralgia_site(4)]=’1’

1

presentation

SYMPTOMS ON ADMISSION: Indicate if experienced at any time from onset of this illness to the day of presentation.

adsym_arthralgia_hand_num

number

How many small joints of hand affected?

number

1

20

([adsym_arthralgia_hand(1)]=’1’ OR [adsym_arthralgia_hand(2)]=’1’ OR [adsym_arthralgia_hand(3)]=’1’) AND [adsym_arthralgia_hand(99)]=’0’

1

presentation

SYMPTOMS ON ADMISSION: Indicate if experienced at any time from onset of this illness to the day of presentation.

adsym_arthralgia_add

checkbox

Indicate other affected joints

1, TMJ | 2, Sternoclavicular (SC) | 3, Acromioclavicular (AC) | 4, Sacroiliac (SI) | 5, Hip | 6, Subtalar | 7, Thoracic spine | 8, Lumbar spine | 88, Other (specify)

[adsym_arthralgia_site(88)]=’1’

1

presentation

SYMPTOMS ON ADMISSION: Indicate if experienced at any time from onset of this illness to the day of presentation.

adsym_arthralgia_add_oth

text

Specify other joint(s)

[adsym_arthralgia_add(88)]=’1’

1

presentation

SYMPTOMS ON ADMISSION: Indicate if experienced at any time from onset of this illness to the day of presentation.

adsym_jointswell

radio

Joint swelling

1, Yes | 0, No | 99, Unknown

Systemic/General

Defined as the buildup of fluid in the soft tissue SURROUNDING the joint or in the joint itself

Indicate ‘Yes’, if the patient has experienced this at any time from onset of this illness to presentation.

SNOMED

271771009, Joint swelling

clinical_features

1

1

presentation

SYMPTOMS ON ADMISSION: Indicate if experienced at any time from onset of this illness to the day of presentation.

adsym_jointswell_site

checkbox

Site where joint swelling occurred

1, Shoulder | 2, Elbow | 3, Wrist | 4, Small joints of hand | 5, Knee | 6, Ankle |7, Small joints of foot | 88, Other

[adsym_jointswell]= ‘1’

Systemic/General,This refers to the location where joint swelling first occurred

1

1

presentation

SYMPTOMS ON ADMISSION: Indicate if experienced at any time from onset of this illness to the day of presentation.

adsym_jointswell_site_shoulder

radio

How many shoulder joints are affected?

1, 1 | 2, 2 | 99, Unknown

[adsym_jointswell_site(1)]=’1’

Systemic/General

1

presentation

SYMPTOMS ON ADMISSION: Indicate if experienced at any time from onset of this illness to the day of presentation.

adsym_jointswell_site_elbow

radio

How many elbow joints are affected?

1, 1 | 2, 2 | 99, Unknown

[adsym_jointswell_site(2)]=’1’

Systemic/General

1

presentation

SYMPTOMS ON ADMISSION: Indicate if experienced at any time from onset of this illness to the day of presentation.

adsym_jointswell_site_wrist

radio

How many wrist joints are affected?

1, 1 | 2, 2 | 99, Unknown

[adsym_jointswell_site(3)]=’1’

Systemic/General

1

presentation

SYMPTOMS ON ADMISSION: Indicate if experienced at any time from onset of this illness to the day of presentation.

adsym_jointswell_site_knee

radio

How many knee joints are affected?

1, 1 | 2, 2 | 99, Unknown

[adsym_jointswell_site(5)]=’1’

Systemic/General

1

presentation

SYMPTOMS ON ADMISSION: Indicate if experienced at any time from onset of this illness to the day of presentation.

adsym_jointswell_site_ankle

radio

How many ankle joints are affected?

1, 1 | 2, 2 | 99, Unknown

[adsym_jointswell_site(6)]=’1’

Systemic/General

1

presentation

SYMPTOMS ON ADMISSION: Indicate if experienced at any time from onset of this illness to the day of presentation.

adsym_jointswell_site_foot

number

How many small joints of the foot are affected?

number

1

14

[adsym_jointswell_site(7)]=’1’

Systemic/General

1

presentation

SYMPTOMS ON ADMISSION: Indicate if experienced at any time from onset of this illness to the day of presentation.

adsym_jointswell_hand

checkbox

Small joints of hand

1, MCP (metacarpophalangeal) joint | 2, PIP (proximal interphalangeal) joint | 3, DIP (distal interphalangeal) joint | 99, Unknown

[adsym_jointswell_site(4)]=’1’

1

presentation

SYMPTOMS ON ADMISSION: Indicate if experienced at any time from onset of this illness to the day of presentation.

adsym_jointswell_hand_num

number

How many small joints of hand affected?

number

1

20

([adsym_jointswell_hand(1)]=’1’ OR [adsym_jointswell_hand(2)]=’1’ OR [adsym_jointswell_hand(3)]=’1’) AND [adsym_jointswell_hand(99)]=’0’

1

presentation

SYMPTOMS ON ADMISSION: Indicate if experienced at any time from onset of this illness to the day of presentation.

adsym_jointswell_add

checkbox

Indicate other affected joints

1, TMJ | 2, Sternoclavicular (SC) | 3, Acromioclavicular (AC) | 4, Sacroiliac (SI) | 5, Hip | 6, Subtalar | 7, Thoracic spine | 8, Lumbar spine | 88, Other (specify)

[adsym_jointswell_site(88)]=’1’

1

1

presentation

SYMPTOMS ON ADMISSION: Indicate if experienced at any time from onset of this illness to the day of presentation.

adsym_jointswell_add_oth

text

Specify other joint(s)

[adsym_jointswell_add(88)]=’1’

1

presentation

SYMPTOMS ON ADMISSION: Indicate if experienced at any time from onset of this illness to the day of presentation.

adsym_jointstiff

radio

Joint stiffness

1, Yes | 0, No | 99, Unknown

1

presentation

SYMPTOMS ON ADMISSION: Indicate if experienced at any time from onset of this illness to the day of presentation.

adsym_jointstiff_scal

number

Stiffness NRS - Patient-reported (0-10)

number

0

10

[adsym_jointstiff]=’1’

1

presentation

SYMPTOMS ON ADMISSION: Indicate if experienced at any time from onset of this illness to the day of presentation.

adsym_jointstiff_dur

number

Morning stiffness duration (min)

number

0

[adsym_jointstiff]=’1’

1

presentation

SYMPTOMS ON ADMISSION: Indicate if experienced at any time from onset of this illness to the day of presentation.

adsym_jointtender

radio

Joint tenderness

1, Yes | 0, No | 99, Unknown

Systemic/General

Defined as pain and discomfort in a joint, often accompanied by sensitivity to touch

Indicate ‘Yes’, if the patient has experienced this at any time from onset of this illness to presentation.

SNOMED

110288007, Tenderness of joint

clinical_features

1

1

presentation

SYMPTOMS ON ADMISSION: Indicate if experienced at any time from onset of this illness to the day of presentation.

adsym_jointtender_site

checkbox

Site where joint tenderness occurred

1, Fingers | 2, Wrists | 3, Shoulders | 4, Elbow | 5, Hips | 8, Knees | 9, Ankles | 10, Toes | 99, Unknown | 88, Other

[adsym_jointtender]= ‘1’

Systemic/General

This refers to the location where joint tenderness first occurred

clinical_features

1

presentation

SYMPTOMS ON ADMISSION: Indicate if experienced at any time from onset of this illness to the day of presentation.

adsym_jointtender_site_oth

text

Specify other first joint tenderness location

[adsym_jointtender_site(88)]=’1’

Systemic/General

This refers to the location where joint tenderness first occurred

clinical_features

1

presentation

SYMPTOMS ON ADMISSION: Indicate if experienced at any time from onset of this illness to the day of presentation.

adsym_stissueswell

radio

Small tissue swelling

1, Yes | 0, No | 99, Unknown

Systemic/General

Defined as painful swelling of the interphalangeal tissue, leading to tension and pain when flexing the fingers

Indicate ‘Yes’, if the patient has experienced this at any time from onset of this illness to presentation.

SNOMED

298349001, Soft tissue swelling

clinical_features

1

presentation

SYMPTOMS ON ADMISSION: Indicate if experienced at any time from onset of this illness to the day of presentation.

adsym_backpain

radio

Back Pain

1, Yes | 0, No | 99, Unknown

Systemic/General

presentation

SYMPTOMS ON ADMISSION: Indicate if experienced at any time from onset of this illness to the day of presentation.

adsym_neckpain

radio

Neck Pain

1, Yes | 0, No | 99, Unknown

Systemic/General

1

presentation

SYMPTOMS ON ADMISSION: Indicate if experienced at any time from onset of this illness to the day of presentation.

adsym_skinrash

radio

Skin rash

1, Yes | 0, No | 99, Unknown

Systemic/General

This refers to any change in the skin which affects its appearance or texture. A rash may be localized to one part of the body or affect all the skin. Rashes may cause the skin to change colour, itch, become warm, bumpy, dry, cracked, or blistered, swell and may be painful.

Indicate ‘Yes’, if the patient has experienced this at any time from onset of this illness to presentation.

SNOMED

271807003, Eruption of skin

C4227880, Skin Rash

clinical_features

1

1

1

1

1

1

1

1

1

presentation

SYMPTOMS ON ADMISSION: Indicate if experienced at any time from onset of this illness to the day of presentation.

adsym_skinrash_site

checkbox

Site where rash first occurred

1, Skin, genital | 2, Skin, non-genital | 3, Mucosa, genital | 4, Mucosa, non-genital | 5, Mouth | 6, Perianal skin | 7, Rectum | 99, Unknown| 88, Other

[adsym_skinrash]=’1’

Systemic/General

This refers to the location where the rash first occurred.

Select the most appropriate option(s) corresponding to the location where the rash first occurred.

1

1

1

1

presentation

SYMPTOMS ON ADMISSION: Indicate if experienced at any time from onset of this illness to the day of presentation.

adsym_skinrash_site_oth

text

Specify other first rash location

[adsym_skinrash_site(88)]=’1’

Systemic/General

This refers to the location where the rash first occurred.

If “other’, Specify the first location the rash developed.

1

1

1

presentation

SYMPTOMS ON ADMISSION: Indicate if experienced at any time from onset of this illness to the day of presentation.

adsym_skinrash_date

date_dmy

Date first rash was observed by patient

date_dmy

today

[adsym_skinrash]=’1’

Systemic/General

This refers to the date the patient reports to have first identified the rash.

Enter the date the patient reports to have first identified the rash. (Use the format DD/MM/YYYY)

A27176536, Date of rash onset

1

1

1

presentation

SYMPTOMS ON ADMISSION: Indicate if experienced at any time from onset of this illness to the day of presentation.

adsym_paresthesia

radio

Skin paresthesia

1, Yes | 0, No | 99, Unknown

[demog_calcage_days]>=365

Systemic/General

This refers to percieved cutaneous sensations (e.g., cold, warmth, tingling, pressure, etc.) that are experienced spontaneously in the absence of stimulation.

Indicate ‘Yes’, if the patient has experienced this at any time from onset of this illness to presentation.

91019004, Paresthesia (finding)

1

1

presentation

SYMPTOMS ON ADMISSION: Indicate if experienced at any time from onset of this illness to the day of presentation.

adsym_skinchange

radio

Changes in skin texture

1, Yes | 0, No | 99, Unknown

Systemic/General

This refers to alterations in the surface appearance and feel of the skin, such as roughness, unevenness, or the presence of bumps.

Indicate ‘Yes’, if the patient has experienced this at any time from onset of this illness to presentation.

274672009, Changes in skin texture (finding)

C0159040, Changes in skin texture

1

presentation

SYMPTOMS ON ADMISSION: Indicate if experienced at any time from onset of this illness to the day of presentation.

adsym_skinpallor

radio

Skin pallor

1, Yes | 0, No | 99, Unknown

Systemic/General

This refers to unnatural pale appearance of the skin.

Indicate ‘Yes’, if the patient has experienced this at any time from onset of this illness to presentation.

1209208002, Pallor of skin or face

C0241137, Pallor of skin

1

presentation

SYMPTOMS ON ADMISSION: Indicate if experienced at any time from onset of this illness to the day of presentation.

adsym_pruritus

radio

Itch (pruritus)

1, Yes | 0, No | 99, Unknown

[demog_calcage_days]>=183

Systemic/General

Defined as an unpleasant or intense itching sensation that produces the urge to rub or scratch the skin to obtain relief. Itching is an irritating sensation that makes you want to scratch your skin.

Indicate ‘Yes’, if the patient has experienced this at any time from onset of this illness to presentation.

SNOMED

418363000, Itching of skin

C0033774, Pruritus

clinical_features

1

1

1

1

1

presentation

SYMPTOMS ON ADMISSION: Indicate if experienced at any time from onset of this illness to the day of presentation.

adsym_mobilchg

radio

Change in mobility from baseline

1, Yes | 0, No | 99, Unknown

Systemic/General

This refers to the patient’s ability to walk or mobilise.

Indicate ‘Yes’, if the patient has experienced this at any time from onset of this illness to presentation.

clinical_features

1

1

1

1

1

1

presentation

SYMPTOMS ON ADMISSION: Indicate if experienced at any time from onset of this illness to the day of presentation.

adsym_mobile

radio

Mobility status

1, Fully ambulant | 2, Ambulant, but with some assistance | 3, Bedridden

[demog_calcage_days]>=1825

Systemic/General

This refers to the patient’s ability to walk or mobilise.

Indicate the patient’s mobility status at the time of presentation.

SNOMED

160680006, Fully mobile | 427512004, Dependent for walking | 160685001, Bed-ridden

C0231435, Mobile | CL573260, Walks with assistance | C0425251, Bed-ridden

clinical_features

1

1

1

1

1

1

presentation

SYMPTOMS ON ADMISSION: Indicate if experienced at any time from onset of this illness to the day of presentation.

adsym_sleepmore

radio

Sleeping more than usual / lethargic / sluggish / listlessness

1, Yes | 0, No | 99, Unknown

Systemic/General

This refers to excessive sleepiness during the daytime / marked by drowsiness and an unusual lack of energy and mental alertness / infant having little energy, is drowsy, or sleeps more than usual

Indicate ‘Yes’, if the patient has experienced this at any time from onset of this illness to presentation.

SNOMED

214264003, Lethargy (finding)

C0023380, Lethargy

1

1

presentation

SYMPTOMS ON ADMISSION: Indicate if experienced at any time from onset of this illness to the day of presentation.

adsym_polydipsia

radio

Increased thirst (polydipsia)

1, Yes | 0, No | 99, Unknown

[demog_calcage_days]>=365

Systemic/General

This refers to excessive thirst

Indicate ‘Yes’, if the patient has experienced this at any time from onset of this illness to presentation.

SNOMED

82800008, Primary polydipsia

C0085602, Polydipsia

1

presentation

SYMPTOMS ON ADMISSION: Indicate if experienced at any time from onset of this illness to the day of presentation.

adsym_irregmenstruation

radio

Changes in menstruation / Irregular menstruation

1, Yes | 0, No | 99, Unknown

[demog_sex]=’2’ and [demog_calcage_days]>=2920

Systemic/General

This refers to any deviations from the normal process; e.g. delayed, difficult, profuse, scanty, unusual bleeding, etc.

Indicate ‘Yes’, if the patient has experienced this at any time from onset of this illness to presentation.

80182007, Irregular periods

C0156404, Irregular menstruation

1

presentation

SYMPTOMS ON ADMISSION: Indicate if experienced at any time from onset of this illness to the day of presentation.

adsym_resp

descriptive

Respiratory symptoms

Respiratory

This refers to signs and symptoms relating to the respiratory system.

Indicate ‘Yes’, if the patient has experienced this at any time from onset of this illness to presentation.

1

1

1

1

1

1

1

1

1

presentation

SYMPTOMS ON ADMISSION: Indicate if experienced at any time from onset of this illness to the day of presentation.

adsym_cough

radio

Cough

1, Yes | 0, No | 99, Unknown

Respiratory

This refers to the presence of a cough and its characteristics. A productive cough refers to a cough accompanied by expectorated secretions (phlegm or mucus), while a non-productive cough refers to one which is not accompanied by expectorated secretions. Haemoptysis refers to the presence of blood or blood-streaked sputum from the respiratory tract.

Indicate ‘Yes’, if the patient has experienced this at any time from onset of this illness to presentation.

SNOMED

49727002, Cough (finding)

C0010200, Coughing

clinical_features

1

1

1

1

1

1

1

1

1

presentation

SYMPTOMS ON ADMISSION: Indicate if experienced at any time from onset of this illness to the day of presentation.

adsym_cough_type

radio

Cough type

1, Non Productive | 2, Productive |3, Haemoptysis |99, Unknown

[adsym_cough] = ‘1’

Respiratory

This refers to the type of cough. A productive cough refers to a cough accompanied by expectorated secretions (phlegm or mucus)

Indicate ‘Yes’, if the patient has experienced this at any time from onset of this illness to presentation.

SNOMED

28743005 Productive Cough

C0451597 Productive Cough

clinical_features

1

1

1

1

1

1

1

1

1

presentation

SYMPTOMS ON ADMISSION: Indicate if experienced at any time from onset of this illness to the day of presentation.

adsym_sorethroat

radio

Sore throat

1, Yes | 0, No | 99, Unknown

[demog_calcage_days]>=365

Respiratory

Defined as an unpleasant sensation characterized by physical discomfort (such as pricking, throbbing, or aching) and perceived to originate in the throat.

Indicate ‘Yes’, if the patient has experienced this at any time from onset of this illness to presentation.

SNOMED

267102003, Sore throat

C3854544, Sore throat

clinical_features

1

1

1

1

1

1

1

1

presentation

SYMPTOMS ON ADMISSION: Indicate if experienced at any time from onset of this illness to the day of presentation.

adsym_rhinorrhoe

radio

Runny nose (rhinorrhoea)

1, Yes | 0, No | 99, Unknown

Respiratory

Defined as increased mucosal discharge of the nose.

Indicate ‘Yes’, if the patient has experienced this at any time from onset of this illness to presentation.

SNOMED

64531003, Nasal Discharge

C1260880, Rhinorrhea

clinical_features

1

1

1

1

1

1

presentation

SYMPTOMS ON ADMISSION: Indicate if experienced at any time from onset of this illness to the day of presentation.

adsym_wheezing

radio

Wheezing

1, Yes | 0, No | 99, Unknown

Respiratory

Defined as a high-pitched breath sound resulting from a narrowing or obstruction of the small airway.

Indicate ‘Yes’, if the patient has experienced this at any time from onset of this illness to presentation.

SNOMED

56018004, Wheezing

C0043144, Wheezing

clinical_features

1

1

1

1

presentation

SYMPTOMS ON ADMISSION: Indicate if experienced at any time from onset of this illness to the day of presentation.

adsym_shortbreat

radio

Shortness of breath

1, Yes | 0, No | 99, Unknown

[demog_calcage_days]>=365

Respiratory

Defined as the uncomfortable sensation of difficult or laboured breathing that is out of proportion to the patient’s level of physical activity.

Indicate ‘Yes’, if the patient has experienced this at any time from onset of this illness to presentation.

SNOMED

267036007, Dyspn

C4230442, Dyspnea

clinical_features

1

1

1

1

1

1

1

1

1

presentation

SYMPTOMS ON ADMISSION: Indicate if experienced at any time from onset of this illness to the day of presentation.

adsym_nasalcongestion

radio

Nasal congestion

1, Yes | 0, No | 99, Unknown

Respiratory

Defined as reduced ability to pass air through the nasal cavity often leading to mouth breathing.

Indicate ‘Yes’, if the patient has experienced this at any time from onset of this illness to presentation.

68235000, Nasal congestion

C0027424, Nasal congestion

clinical_features

1

1

presentation

SYMPTOMS ON ADMISSION: Indicate if experienced at any time from onset of this illness to the day of presentation.

adsym_chestpain

radio

Chest pain

1, Yes | 0, No | 99, Unknown

[demog_calcage_days]>=365

Respiratory

Defined as the unpleasant, uncomfortable or painful sensation characterised by physical discomfort localised to the chest.

Indicate ‘Yes’, if the patient has experienced this at any time from onset of this illness to presentation.

SNOMED

29857009, Chest pain

C0008031, Chest pain

clinical_features

1

1

1

1

1

1

1

presentation

SYMPTOMS ON ADMISSION: Indicate if experienced at any time from onset of this illness to the day of presentation.

adsym_sneez

radio

Sneezing

1, Yes | 0, No | 99, Unknown

Respiratory

This refers to a sudden violent, spasmodic, audible expiration of breath through the nose and mouth.

Indicate ‘Yes’, if the patient has experienced this at any time from onset of this illness to presentation.

SNOMED

76067001, Sneezing

C0037383, Sneezing

1

presentation

SYMPTOMS ON ADMISSION: Indicate if experienced at any time from onset of this illness to the day of presentation.

adsym_hiccups

radio

Hiccups

1, Yes | 0, No | 99, Unknown

Respiratory

presentation

SYMPTOMS ON ADMISSION: Indicate if experienced at any time from onset of this illness to the day of presentation.

adsym_cvs

descriptive

Cardiovascular symptoms

Cardiovascular

This refers to signs and symptoms relating to the cardiovascular system.

Indicate ‘Yes’, if the patient has experienced this at any time from onset of this illness to presentation.

clinical_features

1

1

1

1

presentation

SYMPTOMS ON ADMISSION: Indicate if experienced at any time from onset of this illness to the day of presentation.

adsym_palpitations

radio

Palpitations

1, Yes | 0, No | 99, Unknown

Cardiovascular

Refers to the unpleasant awareness of one’s own heartbeat.

Indicate ‘Yes’, if the patient has experienced this at any time from onset of this illness to presentation.

SNOMED

80313002, Palpitations (finding)

clinical_features

1

1

1

1

presentation

SYMPTOMS ON ADMISSION: Indicate if experienced at any time from onset of this illness to the day of presentation.

adsym_git

descriptive

Gastrointestinal symptoms

Gastrointestinal

This refers to signs and symptoms relating to the gastrointestinal system.

Indicate ‘Yes’, if the patient has experienced this at any time from onset of this illness to presentation.

clinical_features

1

1

1

1

1

1

1

1

1

presentation

SYMPTOMS ON ADMISSION: Indicate if experienced at any time from onset of this illness to the day of presentation.

adsym_abdpain

radio

Abdominal pain

1, Yes | 0, No | 99, Unknown

[demog_calcage_days]>=365

Gastrointestinal

Defined as an unpleasant sensation of discomfort, distress or agony in the abdominal region.

Indicate ‘Yes’, if the patient has experienced this at any time from onset of this illness to presentation.

SNOMED

21522001, Abdominal pain

C3553274, Abdominal pain

clinical_features

1

1

1

1

1

1

1

1

1

1

presentation

SYMPTOMS ON ADMISSION: Indicate if experienced at any time from onset of this illness to the day of presentation.

adsym_diarrhoea

radio

Diarrhoea

1, Yes | 0, No | 99, Unknown

Gastrointestinal

Defined as abnormally increased frequency (usually defined as three or more) loose or liquid bowel movement per day (or more frequent passage than is normal for the individual).

Indicate ‘Yes’, if the patient has experienced this at any time from onset of this illness to presentation.

SNOMED

62315008, Diarrhea

C3554472, Diarrhea

clinical_features

1

1

1

1

1

1

1

1

1

presentation

SYMPTOMS ON ADMISSION: Indicate if experienced at any time from onset of this illness to the day of presentation.

adsym_consti

radio

Constipation

1, Yes | 0, No | 99, Unknown

Gastrointestinal

Defined as irregular and infrequent or difficult evacuation of the bowels.

Indicate ‘Yes’, if the patient has experienced this at any time from onset of this illness to presentation.

SNOMED

14760008, Constipation

C3551741, Constipation

clinical_features

1

1

presentation

SYMPTOMS ON ADMISSION: Indicate if experienced at any time from onset of this illness to the day of presentation.

adsym_vomit

radio

Vomiting

1, Yes | 0, No | 99, Unknown

Gastrointestinal

Defined as the expulsion of the stomach or small intestines through the mouth.

Indicate ‘Yes’, if the patient has experienced this at any time from onset of this illness to presentation.

SNOMED

422400008, Vomiting

C4230730, Vomiting

clinical_features

1

1

1

1

1

1

1

1

1

presentation

SYMPTOMS ON ADMISSION: Indicate if experienced at any time from onset of this illness to the day of presentation.

adsym_vomit2d

radio

Persistent vomiting? (>=2/day)

1, Yes | 0, No | 99, Unknown

[adsym_vomit]=’1’

Gastrointestinal

This refers to persistent vomiting, defined here as vomiting two times or more per day.

Indicate ‘Yes’, if the patient has experienced this at any time from onset of this illness to presentation.

SNOMED

196746003, Persistent vomiting

C0152165, Persistent vomiting

clinical_features

1

1

1

1

1

1

1

1

presentation

SYMPTOMS ON ADMISSION: Indicate if experienced at any time from onset of this illness to the day of presentation.

adsym_vomitbld

radio

Vomiting blood (haematemesis)

1, Yes | 0, No | 99, Unknown

[adsym_vomit]=’1’

Gastrointestinal

This refers to vomiting of blood.

Indicate ‘Yes’, if the patient has experienced this at any time from onset of this illness to presentation.

SNOMED

8765009, Haematemesis

C0018926, Haematemesis

clinical_features

1

presentation

SYMPTOMS ON ADMISSION: Indicate if experienced at any time from onset of this illness to the day of presentation.

adsym_nausea

radio

Nausea

1, Yes | 0, No | 99, Unknown

[demog_calcage_days]>=1095

Gastrointestinal

Defined as the the unpleasant painless subjective feeling that one will imminently vomit.

Indicate ‘Yes’, if the patient has experienced this at any time from onset of this illness to presentation.

SNOMED

422587007, Nausea

C3554470, Nausea

clinical_features

1

1

1

1

1

1

1

presentation

SYMPTOMS ON ADMISSION: Indicate if experienced at any time from onset of this illness to the day of presentation.

adsym_anorexia

radio

Anorexia

1, Yes | 0, No | 99, Unknown

Gastrointestinal

Defined as lack or loss of appetite.

Indicate ‘Yes’, if the patient has experienced this at any time from onset of this illness to presentation.

SNOMED

79890006, Loss of appetite

C3554473, Anorexia

clinical_features

1

1

1

1

1

1

1

presentation

SYMPTOMS ON ADMISSION: Indicate if experienced at any time from onset of this illness to the day of presentation.

adsym_exsal

radio

Excessive salivation

1, Yes | 0, No | 99, Unknown

[demog_calcage_days]>=1460

Gastrointestinal

Defined as excessive salivation or sialorrhea, is a symptom best assessed by the patient.

Indicate ‘Yes’, if the patient has experienced this at any time from onset of this illness to presentation.

SNOMED

53827007 | Excessive salivation (disorder) |

C0037036, Sialorrhea

clinical_features

1

1

presentation

SYMPTOMS ON ADMISSION: Indicate if experienced at any time from onset of this illness to the day of presentation.

adsym_diffswallow

radio

Difficulty swallowing (dysphagia)

1, Yes | 0, No | 99, Unknown

Gastrointestinal

Defined as difficulty swallowing food, liquids, or saliva.

Indicate ‘Yes’, if the patient has experienced this at any time from onset of this illness to presentation.

SNOMED

40739000, Dysphagia (disorder)

C0011168, Deglutition Disorders

clinical_features

1

1

1

presentation

SYMPTOMS ON ADMISSION: Indicate if experienced at any time from onset of this illness to the day of presentation.

adsym_faecalincont

radio

Faecal incontinence

1, Yes | 0, No | 99, Unknown

[demog_calcage_days]>=1825

Gastrointestinal

Defined as failure of voluntary control of the anal sphincters, with involuntary passage of feces and flatus.

Indicate ‘Yes’, if the patient has experienced this at any time from onset of this illness to presentation.

SNOMED

72042002, Incontinence of feces (finding)

C0015732, Fecal Incontinence

clinical_features

1

presentation

SYMPTOMS ON ADMISSION: Indicate if experienced at any time from onset of this illness to the day of presentation.

adsym_renalgut

descriptive

Renal / Genitourinary symptoms

Genitourinary

This refers to signs and symptoms relating to the renal / genitourinary system.

Indicate ‘Yes’, if the patient has experienced this at any time from onset of this illness to presentation.

clinical_features

1

1

presentation

SYMPTOMS ON ADMISSION: Indicate if experienced at any time from onset of this illness to the day of presentation.

adsym_urine

radio

Urinary retention

1, Yes | 0, No | 99, Unknown

Genitourinary

Defined as the accumulation of urine within the bladder because of the inability to urinate.

Indicate ‘Yes’, if the patient has experienced this at any time from onset of this illness to presentation.

SNOMED

267064002, Retention of urine

C0080274, Urinary retention

clinical_features

1

1

presentation

SYMPTOMS ON ADMISSION: Indicate if experienced at any time from onset of this illness to the day of presentation.

adsym_urineincont

radio

Urinary incontinence

1, Yes | 0, No | 99, Unknown

[demog_calcage_days]>=1825

Genitourinary

This refers to loss of bladder control, or being unable to control urination.

Indicate ‘Yes’, if the patient has experienced this at any time from onset of this illness to presentation.

SNOMED

165232002, Urinary incontinence (finding)

C0042024, Urinary Incontinence

clinical_features

1

presentation

SYMPTOMS ON ADMISSION: Indicate if experienced at any time from onset of this illness to the day of presentation.

adsym_polyuria

radio

Increased urination (polyuria)

1, Yes | 0, No | 99, Unknown

Genitourinary

This refers to excessive or frequent urination.

Indicate ‘Yes’, if the patient has experienced this at any time from onset of this illness to presentation.

SNOMED

28442001, Polyuria

C0032617, Polyuria

clinical_features

1

presentation

SYMPTOMS ON ADMISSION: Indicate if experienced at any time from onset of this illness to the day of presentation.

adsym_dysuria

radio

Pain during urination (dysuria)

1, Yes | 0, No | 99, Unknown

[demog_calcage_days]>=365

Genitourinary

This refers to painful or difficult urination.

Indicate ‘Yes’, if the patient has experienced this at any time from onset of this illness to presentation.

SNOMED

49650001, Dysuria

C0013428, Dysuria

clinical_features

1

presentation

SYMPTOMS ON ADMISSION: Indicate if experienced at any time from onset of this illness to the day of presentation.

adsym_dyspareunia

radio

Painful intercourse (dyspareunia)

1, Yes | 0, No | 99, Unknown

[demog_calcage_days]>=5475

Genitourinary

Defined as recurrent or persistent genital pain associated with sexual intercourse.

Indicate ‘Yes’, if the patient has experienced this at any time from onset of this illness to presentation.

SNOMED

71315007, Dyspareunia (finding)

C1384606, Dyspareunia

clinical_features

1

1

presentation

SYMPTOMS ON ADMISSION: Indicate if experienced at any time from onset of this illness to the day of presentation.

adsym_heme

descriptive

Haematological symptoms

Haematology

This refers to signs and symptoms relating to the haematological system.

Indicate ‘Yes’, if the patient has experienced this at any time from onset of this illness to presentation.

clinical_features

1

1

1

1

1

1

1

1

presentation

SYMPTOMS ON ADMISSION: Indicate if experienced at any time from onset of this illness to the day of presentation.

adsym_haemorrhag

radio

Bleeding (haemorrhage)

1, Yes | 0, No | 99, Unknown

Haematology

Defined as the presence of blood in a location in which it is not physiologically normal or loss of blood from the circulation, either internally or externally. This can include epistaxis (blood from nose), gingival bleeding (blood from gums/gingiva), blood from any part of the gastrointestinal tract (gastrointestinal bleeding) or genitourinary tracts (vagina or urethra) including hematuria.

Indicate ‘Yes’, if the patient has experienced this at any time from onset of this illness to presentation.

SNOMED

131148009, Bleeding

C3163616, Blood loss

clinical_features

1

1

1

1

1

1

1

1

1

1

presentation

SYMPTOMS ON ADMISSION: Indicate if experienced at any time from onset of this illness to the day of presentation.

adsym_haemorrhag_sev

radio

Severe bleeding (requires intervention)

1, Yes | 0, No | 99, Unknown

[adsym_haemorrhag] = ‘1’

Haematology

Defined as the severe bleeding / hemorrhage requiring medical intervention for hemostasis and/or hemodynamic support.

Indicate ‘Yes’, if the patient has experienced this at any time from onset of this illness to presentation.

clinical_features

1

1

1

1

1

1

1

1

presentation

SYMPTOMS ON ADMISSION: Indicate if experienced at any time from onset of this illness to the day of presentation.

adsym_haemorrhag_site

multi_list

Specify bleeding site(s)

conditions_Site

[adsym_haemorrhag] = ‘1’

Haematology

This refers to the location of bleeding/haemorrhage site(s).

Select the most appropriate option(s) corresponding to the location of bleeding/haemorrhage site(s).

SNOMED

297968009, Bleeding skin | 271813007 Petechiae | 249366005, Bleeding from nose | 86276007, Bleeding gums | 74474003, Gastrointestinal haemorrhage |34436003, blood in urine | 289530006, Bleeding from vagina

C0574741, Bleeding skin | C3808808, Epistaxis | C0017565, Gingival haemorrrhage | C0017181, Gastrointestinal haemorrhage |C3805433, haematuria | C0566961, Fresh bleeding from vagina

clinical_features

1

1

1

1

1

1

1

1

1

1

presentation

SYMPTOMS ON ADMISSION: Indicate if experienced at any time from onset of this illness to the day of presentation.

adsym_haemorrhag_site_oth

text

Specify other bleeding / haemorrhage site(s)

[adsym_haemorrhag_site(88)]=’1’

Haematology

This refers to the location of bleeding/haemorrhage site(s). Petechiae refer to small reddish or purplish spots in skin or mucous membrane as a result of localised haemorrhage. Nose bleeding refers to haemorrhage localized in the nose. Gum bleeding refers to haemorrhage affecting the gingiva. Gastrointestinal (GI) bleeding refers to haemorrhage in any segment of the gastrointestinal tract from oesophagus to rectum. Urinary tract bleeding refers to haemorrhage originating from any part of the urinary system. Vaginal bleeding refers to haemorrhage originating from vagina, unrelated to normal menstruation.

Enter the other site

SNOMED

297968009, Bleeding skin | 271813007 Petechiae | 249366005, Bleeding from nose | 86276007, Bleeding gums | 74474003, Gastrointestinal haemorrhage |34436003, blood in urine | 289530006, Bleeding from vagina

clinical_features

1

1

1

1

1

1

1

1

1

presentation

SYMPTOMS ON ADMISSION: Indicate if experienced at any time from onset of this illness to the day of presentation.

adsym_cns

descriptive

Neurological symptoms

Nervous system

This refers to signs and symptoms relating to the neurological system.

Indicate ‘Yes’, if the patient has experienced this at any time from onset of this illness to presentation.

1

1

1

1

1

1

1

1

1

presentation

SYMPTOMS ON ADMISSION: Indicate if experienced at any time from onset of this illness to the day of presentation.

adsym_headache

radio

Headache

1, Yes | 0, No | 99, Unknown

[demog_calcage_days]>=365

Nervous system

Defined as the experience of pain in various parts of the head.

Indicate ‘Yes’, if the patient has experienced this at any time from onset of this illness to presentation.

SNOMED

25064002, Headache

C0018681, Headache

clinical_features

1

1

1

1

1

1

1

1

1

presentation

SYMPTOMS ON ADMISSION: Indicate if experienced at any time from onset of this illness to the day of presentation.

adsym_photoph

radio

Photophobia

1, Yes | 0, No | 99, Unknown

Nervous system

Refers to increased sensitivity of the eyes to light.

Indicate ‘Yes’, if the patient has experienced this at any time from onset of this illness to presentation.

SNOMED

409668002 | Photophobia (finding) |

C3807325, Photophobia

clinical_features

1

1

1

1

presentation

SYMPTOMS ON ADMISSION: Indicate if experienced at any time from onset of this illness to the day of presentation.

adsym_seizconv

radio

Seizures / convulsions

1, Yes | 0, No | 99, Unknown

Nervous system

Defined as an intermittent abnormality of nervous system physiology characterised by a transient occurrence of sudden, violent, irregular movement of the body, caused by involuntary contraction of muscles due to abnormal excessive or synchronous neuronal activity in the brain.

Indicate ‘Yes’, if the patient has experienced this at any time from onset of this illness to presentation.

SNOMED

91175000, Seizure

C2748942, Seizure

clinical_features

1

1

1

1

1

1

1

1

1

presentation

SYMPTOMS ON ADMISSION: Indicate if experienced at any time from onset of this illness to the day of presentation.

adsym_confusion

radio

Altered consciousness / confusion

1, Yes | 0, No | 99, Unknown

Nervous system

Defined as a level of awareness or arousal other than the patient’s normal baseline.

Indicate ‘Yes’, if the patient has experienced this at any time from onset of this illness to presentation.

SNOMED

443371007, Decreased level of consciousness

C0150450, Altered level of consciousness

clinical_features

1

1

1

1

1

1

1

1

presentation

SYMPTOMS ON ADMISSION: Indicate if experienced at any time from onset of this illness to the day of presentation.

adsym_paralysis

radio

Paralysis

1, Yes | 0, No | 99, Unknown

Nervous system

This refers to inability to fully move or control movement

Indicate ‘Yes’, if the patient has experienced this at any time from onset of this illness to presentation.

SNOMED

44695005, Paralysis (finding)

C0522224, Paralysed

clinical_features

1

1

1

presentation

SYMPTOMS ON ADMISSION: Indicate if experienced at any time from onset of this illness to the day of presentation.

adsym_irritable

radio

Irritability

1, Yes | 0, No | 99, Unknown

Nervous system

Refers to an abnormal or excessive excitability with easily triggered anger, annoyance, or impatience.

Indicate ‘Yes’, if the patient has experienced this at any time from onset of this illness to presentation.

SNOMED

55929007, Feeling irritable (finding)

C0022107, Irritable Mood

clinical_features

1

1

1

presentation

SYMPTOMS ON ADMISSION: Indicate if experienced at any time from onset of this illness to the day of presentation.

adsym_tremor

radio

Tremor

1, Yes | 0, No | 99, Unknown

Nervous system

Refers to an unintentional, oscillating to-and-fro muscle movement about a joint axis.

Indicate ‘Yes’, if the patient has experienced this at any time from onset of this illness to presentation.

SNOMED

26079004 | Tremor (finding) |

C0040822, Tremor

clinical_features

1

1

1

presentation

SYMPTOMS ON ADMISSION: Indicate if experienced at any time from onset of this illness to the day of presentation.

adsym_diffwalk

radio

Difficulty in walking

1, Yes | 0, No | 99, Unknown

[demog_calcage_days]>=292

Nervous system

This refers to any persistent problem with walking.

Indicate ‘Yes’, if the patient has experienced this at any time from onset of this illness to presentation.

SNOMED

719232003, Difficulty walking (finding)

C0311394, Difficulty walking

clinical_features

1

1

presentation

SYMPTOMS ON ADMISSION: Indicate if experienced at any time from onset of this illness to the day of presentation.

adsym_neurologic

radio

Other neurological symptoms

1, Yes | 0, No | 99, Unknown

Nervous system

This refers the presence of an alternative neurological abnormality not listed above.

Indicate ‘Yes’, if the patient has another neurological abnormality not listed above.

clinical_features

1

1

1

presentation

SYMPTOMS ON ADMISSION: Indicate if experienced at any time from onset of this illness to the day of presentation.

adsym_neurologic_spec

text

Specify other neurological symptoms

[adsym_neurologic] = ‘1’

Nervous system

This refers the presence of another neurological abnormality not listed above.

If ‘Other’, specify neurological abnormality.

clinical_features

1

1

presentation

SYMPTOMS ON ADMISSION: Indicate if experienced at any time from onset of this illness to the day of presentation.

adsym_eye

descriptive

Ophthalmological symptoms

Ocular

This refers to signs and symptoms relating to the eye.

Indicate ‘Yes’, if the patient has experienced this at any time from onset of this illness to presentation.

1

1

1

1

1

1

presentation

SYMPTOMS ON ADMISSION: Indicate if experienced at any time from onset of this illness to the day of presentation.

adsym_itchyeye

radio

Itching of eye(s)

1, Yes | 0, No | 99, Unknown

[demog_calcage_days]>=365

Ocular

Defined as itching of one or both eyes.

Indicate ‘Yes’, if the patient has experienced this at any time from onset of this illness to presentation.

SNOMED

74776002, Itching of eye (finding)

C0022281, Itching of eye

clinical_features

1

1

1

1

presentation

SYMPTOMS ON ADMISSION: Indicate if experienced at any time from onset of this illness to the day of presentation.

adsym_redeye

radio

Red / Pink eye(s)

1, Yes | 0, No | 99, Unknown

Ocular

Defined as inflammation or infection of the conjunctiva, characterized by redness in one or both eyes.

Indicate ‘Yes’, if the patient has experienced this at any time from onset of this illness to presentation.

SNOMED

703630003, Red eye

C0235267, Redness of eye

clinical_features

1

1

1

1

1

1

presentation

SYMPTOMS ON ADMISSION: Indicate if experienced at any time from onset of this illness to the day of presentation.

adsym_paineyes

radio

Pain in eye(s)

1, Yes | 0, No | 99, Unknown

Ocular

Defined as discomfort or aching localized within or around the eye area.

Indicate ‘Yes’, if the patient has experienced this at any time from onset of this illness to presentation.

SNOMED

41652007, Pain in eye

C0151827, Eye pain

clinical_features

1

1

1

1

presentation

SYMPTOMS ON ADMISSION: Indicate if experienced at any time from onset of this illness to the day of presentation.

adsym_eyelidedema

radio

Oedema of eyelid(s)

1, Yes | 0, No | 99, Unknown

Ocular

Defined as swelling due to fluid accumulation in the tissues of the eyelid.

Indicate ‘Yes’, if the patient has experienced this at any time from onset of this illness to presentation.

SNOMED

89091004, Oedema of eyelid

C0162285, Oedema of eyelid

clinical_features

1

1

presentation

SYMPTOMS ON ADMISSION: Indicate if experienced at any time from onset of this illness to the day of presentation.

adsym_eyedischarg

radio

Discharge from eye(s)

1, Yes | 0, No | 99, Unknown

Ocular

Defined as the release of fluids ranging from clear to pus-like from the eye, often indicative of infection or irritation.

Indicate ‘Yes’, if the patient has experienced this at any time from onset of this illness to presentation.

SNOMED

246679005, Discharge from eye

C0423006, Discharge from eye

clinical_features

1

1

1

presentation

SYMPTOMS ON ADMISSION: Indicate if experienced at any time from onset of this illness to the day of presentation.

adsym_hazyvision

radio

Hazy / Blurred vision

1, Yes | 0, No | 99, Unknown

Ocular

Defined as a loss of visual acuity, resulting in unclear or distorted sight.

Indicate ‘Yes’, if the patient has experienced this at any time from onset of this illness to presentation.

SNOMED

246636008, Hazy vision

C0344232, Blurred vision

clinical_features

1

1

1

1

presentation

SYMPTOMS ON ADMISSION: Indicate if experienced at any time from onset of this illness to the day of presentation.

adsym_eyelightsensi

radio

Sensitivity of eye to light

1, Yes | 0, No | 99, Unknown

Ocular

Defined as an abnormal intolerance to light, causing discomfort or pain in the eyes when exposed to bright light.

Indicate ‘Yes’, if the patient has experienced this at any time from onset of this illness to presentation.

SNOMED

1285284009, Sensitivity of eye to light

C1698258, Sensitivity of eye to light

clinical_features

1

1

1

presentation

SYMPTOMS ON ADMISSION: Indicate if experienced at any time from onset of this illness to the day of presentation.

adsym_visdist

radio

Visual disturbance

1, Yes | 0, No | 99, Unknown

Ocular

Refers to an interference to normal eyesight without necessarily affecting visual acuity.

Indicate ‘Yes’, if the patient has experienced this at any time from onset of this illness to presentation.

SNOMED

63102001, Visual distrubance

C0547030, Visual disturbance

clinical_features

1

1

1

presentation

SYMPTOMS ON ADMISSION: Indicate if experienced at any time from onset of this illness to the day of presentation.

adsym_ocularoth

radio

Other opthalmological symptoms

1, Yes | 0, No | 99, Unknown

Ocular

This refers to other signs and symptoms relating to the eye, not specified above.

Indicate ‘Yes’, if the patient has experienced this at any time from onset of this illness to presentation.

1

1

1

presentation

SYMPTOMS ON ADMISSION: Indicate if experienced at any time from onset of this illness to the day of presentation.

adsym_ocularoth_spec

text

Specify other opthalmological symptoms

Ocular

This refers to other signs and symptoms relating to the eye, not specified above.

If ‘Yes’, specify other opthalmological signs and symptoms

1

1

1

presentation

SYMPTOMS ON ADMISSION: Indicate if experienced at any time from onset of this illness to the day of presentation.

adsym_ent

descriptive

Ear/Nose/Throat symptoms

ENT

This refers to signs and symptoms relating to the ear, nose and throat.

Indicate ‘Yes’, if the patient has experienced this at any time from onset of this illness to presentation.

clinical_features

1

1

presentation

SYMPTOMS ON ADMISSION: Indicate if experienced at any time from onset of this illness to the day of presentation.

adsym_earpain

radio

Ear pain

1, Yes | 0, No | 99, Unknown

ENT

This refers to painful sensation in the ear

Indicate ‘Yes’, if the patient has experienced this at any time from onset of this illness to presentation.

SNOMED

301354004, Pain of ear

C0013456, Earache

clinical_features

1

1

presentation

SYMPTOMS ON ADMISSION: Indicate if experienced at any time from onset of this illness to the day of presentation.

adsym_tinnitus

radio

Tinnitus

1, Yes | 0, No | 99, Unknown

ENT

This refers to an abnormal perception of sounds experienced by an individual in the absence of auditory stimulation.

Indicate ‘Yes’, if the patient has experienced this at any time from onset of this illness to presentation.

SNOMED

60862001, Tinnitus (finding)

C0040264, Tinnitus

clinical_features

1

1

presentation

SYMPTOMS ON ADMISSION: Indicate if experienced at any time from onset of this illness to the day of presentation.

adsym_parot

radio

Parotitis

1, Yes | 0, No | 99, Unknown

Respiratory

This refers to inflammation of the parotid glands.

Indicate ‘Yes’, if the patient has experienced this at any time from onset of this illness to presentation.

SNOMED

14756005, Parotitis (disorder)

C0030583, Parotitis

clinical_features

presentation

SYMPTOMS ON ADMISSION: Indicate if experienced at any time from onset of this illness to the day of presentation.

adsym_paed

descriptive

Paediatric-specific symptoms

[demog_calcage_days]<=365

Paediatric

1

1

1

presentation

SYMPTOMS ON ADMISSION: Indicate if experienced at any time from onset of this illness to the day of presentation.

adsym_contcry

radio

Continuous crying

1, Yes | 0, No | 99, Unknown

[demog_calcage_days]<=365

Paediatric

1

1

1

presentation

SYMPTOMS ON ADMISSION: Indicate if experienced at any time from onset of this illness to the day of presentation.

adsym_feedingdiff

radio

Feeding difficulty

1, Yes | 0, No | 99, Unknown

[demog_calcage_days]<=365

Paediatric

1

1

1

presentation

SYMPTOMS ON ADMISSION: Indicate if experienced at any time from onset of this illness to the day of presentation.

adsym_otherdesc

descriptive

Other symptoms

Other

1

1

1

1

1

1

1

presentation

SYMPTOMS ON ADMISSION: Indicate if experienced at any time from onset of this illness to the day of presentation.

adsym_unlisted

list

Other symptom(s)

1, Yes | 0, No | 99, Unknown

conditions_Symptoms

Other

This refers to the presence of an alternative sign or abnormality not listed above.

Indicate ‘Yes’, if the patient has experienced this at any time from onset of this illness to presentation.

clinical_features

1

1

1

1

1

1

1

1

presentation

SIGNS ON ADMISSION: Indicate if experienced at any time from onset of this illness to the day of presentation.

adsign_sys

descriptive

Systemic / general signs

Systemic/General

This refers to systemic / general / non-specific signs and symptoms

Indicate ‘Yes’, if the patient has experienced this at any time from onset of this illness to presentation.

1

1

presentation

SIGNS ON ADMISSION: Indicate if experienced at any time from onset of this illness to the day of presentation.

adsign_hypotherm

radio

Hypothermia

1, Yes | 0, No | 99, Unknown

Systemic/General

This refers to abnormally reduced body temperature due to failed thermoregulation.

Indicate ‘Yes’, if the patient has experienced this at any time from onset of this illness to presentation.

SNOMED

386689009, Hypothermia

C0020672, Hypothermia, natural

clinical_features

presentation

SIGNS ON ADMISSION: Indicate if experienced at any time from onset of this illness to the day of presentation.

adsign_coldperiph

radio

Cold / clammy peripheries

1, Yes | 0, No | 99, Unknown

Systemic/General

This refers to skin that feels cool and moist to the touch, often associated with circulatory failure and symptoms like restlessness and hypotension.

Indicate ‘Yes’, if the patient has experienced this at any time from onset of this illness to presentation.

SNOMED

771542000, Cold extremity (finding)

C0277925, Cold extremities

clinical_features

1

presentation

SIGNS ON ADMISSION: Indicate if experienced at any time from onset of this illness to the day of presentation.

adsign_dehyrdation

radio

Dehydration

1, Yes | 0, No | 99, Unknown

Systemic/General

This refers to excessive loss of water from the body.

Indicate ‘Yes’, if the patient has experienced this at any time from onset of this illness to presentation.

SNOMED

34095006, Dehydration (disorder)

C0011175, Dehydration

clinical_features

1

presentation

SIGNS ON ADMISSION: Indicate if experienced at any time from onset of this illness to the day of presentation.

adsign_dehyrdation_type

radio

Dehydration Status

1, Mild | 2, Moderate| 3, Severe

[adsign_dehyrdation]=’1’

Systemic/General

This refers to excessive loss of water from the body.

Indicate ‘Yes’, if the patient has experienced this at any time from onset of this illness to presentation.

SNOMED

34095006, Dehydration (disorder)

C0011175, Dehydration

clinical_features

1

presentation

SIGNS ON ADMISSION: Indicate if experienced at any time from onset of this illness to the day of presentation.

adsign_oedema

radio

Oedema

1, Yes | 0, No | 99, Unknown

Systemic/General

This refers to accumulation of an excessive amount of fluid in cells or intercellular tissues.

Indicate ‘Yes’, if the patient has experienced this at any time from onset of this illness to presentation.

SNOMED

267038008, Oedema (finding)

C0013604, Oedema

1

1

1

1

presentation

SIGNS ON ADMISSION: Indicate if experienced at any time from onset of this illness to the day of presentation.

adsign_oedema_site

checkbox

Oedema site(s)

1, Feet | 2, Ankle | 3, Legs (below knee) | 4, Legs (above knees) | 5, Scrotum/Labia | 6, Sacrum | 7, Abdomen | 8, Neck | 9, Face | 99, Unknown | 88, Other

[adsign_oedema] = ‘1’

Systemic/General

This refers to the location of the odema.

If ‘Yes’, specify the location of the oedema. Select all that apply.

1

1

presentation

SIGNS ON ADMISSION: Indicate if experienced at any time from onset of this illness to the day of presentation.

adsign_oedema_site_oth

text

Specify other oedema site(s)

[adsign_oedema_site(88)] = ‘1’

Systemic/General

This refers to the location of the odema.

If ‘Other’, specify the site of oedema

presentation

SIGNS ON ADMISSION: Indicate if experienced at any time from onset of this illness to the day of presentation.

adsign_lymph

radio

Lymphadenopathy

1, Yes-painful | 2, Yes-not painful | 0, No | 99, Unknown

Systemic/General

Defined as a clinical finding of abnormal enlargement of the lymph nodes.

Indicate ‘Yes’, if the patient has experienced this at any time from onset of this illness to presentation.

SNOMED

30746006, Lymphadenopathy

C4014613, Lymphadenopathy

clinical_features

1

presentation

SIGNS ON ADMISSION: Indicate if experienced at any time from onset of this illness to the day of presentation.

adsign_lymph_site

checkbox

Specify lymphadenopathy site(s)

1, Axillary (arm pits) | 2, Cervical (neck)| 3, Inguinal (groin) | 99, Unknown | 88, Other

[adsign_lymph]=’1’ or [adsign_lymph]=’2’

Systemic/General

This refers to the location in which lymphadenopathy was identified.

Select the most appropriate option(s) corresponding to the location of lymphadenopathy.

SNOMED

clinical_features

1

presentation

SIGNS ON ADMISSION: Indicate if experienced at any time from onset of this illness to the day of presentation.

adsign_lymph_site_oth

text

Specify other lymphadenopathy site(s)

[adsign_lymph_site(88)]=’1’

Systemic/General

This refers to the location in which lymphadenopathy was identified.

If ‘Other’, write the location in which lymphadenopathy was identified.

clinical_features

presentation

SIGNS ON ADMISSION: Indicate if experienced at any time from onset of this illness to the day of presentation.

adsign_bruise

radio

Bruising

1, Yes | 0, No | 99, Unknown

Systemic/General

This refers to spontaneous extravasation of blood into the subcutaneous space, also referred to as spontaneous ecchymoses.

Indicate ‘Yes’, if the patient has experienced this at any time from onset of this illness to presentation.

SNOMED

125667009, Bruising

C0009938, Contusions

clinical_features

1

presentation

SIGNS ON ADMISSION: Indicate if experienced at any time from onset of this illness to the day of presentation.

adsign_alopecia

radio

Alopecia

1, Yes | 0, No | 99, Unknown

Systemic/General

This refers to absence of hair (nonscarring hair loss) from areas where it is normally present.

Indicate ‘Yes’, if the patient has experienced this at any time from onset of this illness to presentation.

SNOMED

56317004, Alopecia

C0002170, Alopecia

clinical_features

presentation

SIGNS ON ADMISSION: Indicate if experienced at any time from onset of this illness to the day of presentation.

adsign_dryskin

radio

Dry skin

1, Yes | 0, No | 99, Unknown

Systemic/General

This refers to skin characterized by the lack of natural or normal moisture resulting from inadequate hydrolipids in the skin, also called xerosis cutis.

Indicate ‘Yes’, if the patient has experienced this at any time from onset of this illness to presentation.

SNOMED

52475004, Xeroderma (disorder)

C0151908, Dry skin

clinical_features

presentation

SIGNS ON ADMISSION: Indicate if experienced at any time from onset of this illness to the day of presentation.

adsign_oralulcer

radio

Oral ulcers

1, Yes | 0, No | 99, Unknown

Systemic/General

This refers to recurrent episodes of ulceration of the oral mucosa (recurrent oral aphthae), typically presenting as painful, sharply circumscribed fibrin-covered mucosal defects with a h

Indicate ‘Yes’, if the patient has experienced this at any time from onset of this illness to presentation.

SNOMED

26284000, Ulcer of mouth

C0149745, Oral ulcer

clinical_features

presentation

SIGNS ON ADMISSION: Indicate if experienced at any time from onset of this illness to the day of presentation.

adsign_mastitis

radio

Mastitis

1, Yes | 0, No | 99, Unknown

Breast

Defined as a inflammation of the breast, with or without accompanying infection

Indicate ‘Yes’, if the patient has experienced this at any time from onset of this illness to presentation.

SNOMED

266579006, Inflammatory disorder of breast (disorder)

C0149613, Acute mastitis

clinical_features

presentation

SIGNS ON ADMISSION: Indicate if experienced at any time from onset of this illness to the day of presentation.

adsign_bacsi

radio

Bacterial super-infection

1, Yes | 0, No | 99, Unknown

Systemic/General

Defined as a physician-diagnosed secondary bacterial infection that occurs during an existing wound, infection or immediately following an earlier infection.

Indicate ‘Yes’, if the patient has experienced this at any time from onset of this illness to presentation.

SNOMED

C0442886, Secondary infections

clinical_features

presentation

SIGNS ON ADMISSION: Indicate if experienced at any time from onset of this illness to the day of presentation.

adsign_bacsi_spec

checkbox

Specify bacterial super-infection.

7, Deep tissue abscess | 1, Folliculitis / cellulitis | 2, Pneumonia | 3, Gastroenteritis | 4, CNS | 5, Bacteraemia | 6, Urinary tract | 88, Other

[adsign_bacsi]=’1’

Systemic/General

This refers to the type or location of the bacterial super-infection.

Select the most appropriate option(s) represents the type or location of the bacterial super-infection.

SNOMED

C0037278, Skin Infection | C0339952, Secondary bacterial pneumonia | C0558348, Bacterial gastroenteritis | C0752180, Bacterial infection of central nervous system | C1096222, Urinary tract infection bacterial

clinical_features

presentation

SIGNS ON ADMISSION: Indicate if experienced at any time from onset of this illness to the day of presentation.

adsign_bacsi_oth

text

Specify other bacterial super-infection

[adsign_bacsi_spec(88)]=’1’

Systemic/General

This refers to the other type(s) or location(s) of the bacterial super-infection, not specified above.

If ‘Other’, write the type or location of the bacterial super-infection.

clinical_features

presentation

SIGNS ON ADMISSION: Indicate if experienced at any time from onset of this illness to the day of presentation.

adsign_resp

descriptive

Respiratory signs

Respiratory

This refers to signs and symptoms relating to the respiratory system.

Indicate ‘Yes’, if the patient has experienced this at any time from onset of this illness to presentation.

1

1

presentation

SIGNS ON ADMISSION: Indicate if experienced at any time from onset of this illness to the day of presentation.

adsign_respdistress

radio

Respiratory distress

1, Yes | 0, No | 99, Unknown

Respiratory

This refer to a pathological increase in the effort and frequency of breathing movements.

Indicate ‘Yes’, if the patient has experienced this at any time from onset of this illness to presentation.

SNOMED

271825005, Respiratory distress

C0476273, Respiratory distress

clinical_features

1

1

presentation

SIGNS ON ADMISSION: Indicate if experienced at any time from onset of this illness to the day of presentation.

adsign_chestindrw

radio

Lower chest wall indrawing

1, Yes | 0, No | 99, Unknown

Respiratory

Defined as a clinical sign of respiratory distress, distinguished by the abnormal inward movement of the lower chest wall during inspiration. If only the soft tissue between the ribs or above the clavicle goes in when the patient breathes, this is not lower chest wall in-drawing.

Indicate ‘Yes’, if the patient has experienced this at any time from onset of this illness to presentation.

SNOMED

67909005, Chest wall retraction (finding)

C0231906, Chest wall retraction

clinical_features

presentation

SIGNS ON ADMISSION: Indicate if experienced at any time from onset of this illness to the day of presentation.

adsign_tachypnoea

radio

Fast breathing (tachypnoea)

1, Yes | 0, No | 99, Unknown

Respiratory

Defined as an abnormal increase of rate of breathing.

Indicate ‘Yes’, if the patient has experienced this at any time from onset of this illness to presentation.

SNOMED

271823003, Tachypnea (finding)

C0231835, Tachypnea

clinical_features

1

presentation

SIGNS ON ADMISSION: Indicate if experienced at any time from onset of this illness to the day of presentation.

adsign_apnoea

radio

Apnoea

1, Yes | 0, No | 99, Unknown

Respiratory

Defined as a transient absence in spontaneous respiration.

Indicate ‘Yes’, if the patient has experienced this at any time from onset of this illness to presentation.

SNOMED

1023001, Apnea (finding)

C0003578, Apnea

clinical_features

presentation

SIGNS ON ADMISSION: Indicate if experienced at any time from onset of this illness to the day of presentation.

adsign_rhinitis

radio

Rhinitis

1, Yes | 0, No | 99, Unknown

Respiratory

Defined as inflammation of the mucous membrane lining the nose, usually associated with nasal discharge.

Indicate ‘Yes’, if the patient has experienced this at any time from onset of this illness to presentation.

SNOMED

70076002, Rhinitis (disorder)

C0035455, Rhinitis

clinical_features

presentation

SIGNS ON ADMISSION: Indicate if experienced at any time from onset of this illness to the day of presentation.

adsign_phary

radio

Pharyngitis

1, Yes | 0, No | 99, Unknown

Respiratory

This refers to the presence of inflammation of the throat..

Indicate ‘Yes’, if the patient has experienced this at any time from onset of this illness to presentation.

SNOMED

405737000, Pharyngitis (disorder)

C0031350, Pharyngitis

clinical_features

presentation

SIGNS ON ADMISSION: Indicate if experienced at any time from onset of this illness to the day of presentation.

adsign_pharery

radio

Pharyngeal erythema

1, Yes | 0, No | 99, Unknown

Respiratory

Indicate ‘Yes’, if the patient has experienced this at any time from onset of this illness to presentation.

clinical_features

presentation

SIGNS ON ADMISSION: Indicate if experienced at any time from onset of this illness to the day of presentation.

adsign_pharexu

radio

Pharyngeal exudate

1, Yes | 0, No | 99, Unknown

Respiratory

Indicate ‘Yes’, if the patient has experienced this at any time from onset of this illness to presentation.

clinical_features

presentation

SIGNS ON ADMISSION: Indicate if experienced at any time from onset of this illness to the day of presentation.

adsign_tonsil

radio

Tonsillitis

1, Yes | 0, No | 99, Unknown

Respiratory

This refers to the presence of inflammation of the tonsils.

Indicate ‘Yes’, if the patient has experienced this at any time from onset of this illness to presentation.

SNOMED

90176007, Tonsillitis (disorder)

C0040425, Tonsillitis

clinical_features

presentation

SIGNS ON ADMISSION: Indicate if experienced at any time from onset of this illness to the day of presentation.

adsign_plueeff

radio

Pleural effusion

1, Yes | 0, No | 99, Unknown

Respiratory

This refers to presence of fluid in the pleural cavity resulting from excessive transudation or exudation from the pleural surfaces.

Indicate ‘Yes’, if the patient has experienced this at any time from onset of this illness to presentation.

SNOMED

60046008, Pleural effusion (disorder)

C0032227, Pleural effusion (disorder)

1

1

presentation

SIGNS ON ADMISSION: Indicate if experienced at any time from onset of this illness to the day of presentation.

adsign_cvs

descriptive

Cardiovascular signs

Cardiovascular

This refers to signs and symptoms relating to the cardiovascular system.

Indicate ‘Yes’, if the patient has experienced this at any time from onset of this illness to presentation.

clinical_features

1

1

presentation

SIGNS ON ADMISSION: Indicate if experienced at any time from onset of this illness to the day of presentation.

adsign_tachycardia

radio

Rapid heart rate (tachycardia)

1, Yes | 0, No | 99, Unknown

Cardiovascular

Refers to an abnormally rapid heart rate (typically > 100bpm for adults), that exceeds the range of the normal resting heart rate for age.

Indicate ‘Yes’, if the patient has experienced this at any time from onset of this illness to presentation.

SNOMED

3424008, Tachycardia (finding)

C0039231, Tachycardia

clinical_features

1

presentation

SIGNS ON ADMISSION: Indicate if experienced at any time from onset of this illness to the day of presentation.

adsign_arrhythmia

radio

Cardiac arrhythmia

1, Yes | 0, No | 99, Unknown

Cardiovascular

Refers to an abnormality in rhythm of heartbeat, including rate, regularity, and/or sequence of activation abnormalities

Indicate ‘Yes’, if the patient has experienced this at any time from onset of this illness to presentation.

SNOMED

698247007, Cardiac arrhythmia (disorder)

C0003811, Cardiac Arrhythmia

clinical_features

1

1

presentation

SIGNS ON ADMISSION: Indicate if experienced at any time from onset of this illness to the day of presentation.

adsign_cyan

radio

Peripheral cyanosis

1, Yes | 0, No | 99, Unknown

Cardiovascular

1

presentation

SIGNS ON ADMISSION: Indicate if experienced at any time from onset of this illness to the day of presentation.

adsign_git

descriptive

Gastrointestinal signs

Gastrointestinal

This refers to signs and symptoms relating to the gastrointestinal system.

Indicate ‘Yes’, if the patient has experienced this at any time from onset of this illness to presentation.

1

1

presentation

SIGNS ON ADMISSION: Indicate if experienced at any time from onset of this illness to the day of presentation.

adsign_ascites

radio

Ascites

1, Yes | 0, No | 99, Unknown

Gastrointestinal

Defined as an excessive accumulation or retention of free fluid within the peritoneal cavity.

Indicate ‘Yes’, if the patient has experienced this at any time from onset of this illness to presentation.

SNOMED

389026000, Ascites (disorder)

C0003962, Ascites

clinical_features

1

presentation

SIGNS ON ADMISSION: Indicate if experienced at any time from onset of this illness to the day of presentation.

adsign_hepatomegally

radio

Palpable liver/Hepatomegaly

1, Yes | 0, No | 99, Unknown

Gastrointestinal

Defined as an pathological enlargement of the liver

Indicate ‘Yes’, if the patient has experienced this at any time from onset of this illness to presentation.

SNOMED

80515008, Large liver (disorder)

C0019209, Hepatomegaly

clinical_features

1

1

1

presentation

SIGNS ON ADMISSION: Indicate if experienced at any time from onset of this illness to the day of presentation.

adsign_splenomegaly

radio

Palpable spleen/splenomegaly

1, Yes | 0, No | 99, Unknown

Gastrointestinal

Indicate ‘Yes’, if the patient has experienced this at any time from onset of this illness to presentation.

clinical_features

1

1

presentation

SIGNS ON ADMISSION: Indicate if experienced at any time from onset of this illness to the day of presentation.

adsign_tenabd

radio

Tender abdomen

1, Yes | 0, No | 99, Unknown

Gastrointestinal

Indicate ‘Yes’, if the patient has experienced this at any time from onset of this illness to presentation.

clinical_features

presentation

SIGNS ON ADMISSION: Indicate if experienced at any time from onset of this illness to the day of presentation.

adsign_jaund

radio

Jaundice

1, Yes | 0, No | 99, Unknown

Gastrointestinal

Defined as a clinical manifestation of hyperbilirubinemia, characterized by the yellowish staining of the skin, mucous membrane and/or sclera.

Indicate ‘Yes’, if the patient has experienced this at any time from onset of this illness to presentation.

SNOMED

18165001, Jaundice

C3549846, Jaundice

clinical_features

1

1

1

presentation

SIGNS ON ADMISSION: Indicate if experienced at any time from onset of this illness to the day of presentation.

adsign_melaena

radio

Dark / tarry blood in faeces (melaena)

1, Yes | 0, No | 99, Unknown

Gastrointestinal

This refers to abnormally dark tarry feces containing blood, usually from gastrointestinal bleeding.

Indicate ‘Yes’, if the patient has experienced this at any time from onset of this illness to presentation.

SNOMED

2901004, Melena (disorder)

C0025222, Melena

clinical_features

1

presentation

SIGNS ON ADMISSION: Indicate if experienced at any time from onset of this illness to the day of presentation.

adsign_haematochezia

radio

Fresh blood in stools (haematochezia)

1, Yes | 0, No | 99, Unknown

Gastrointestinal

This refers to the presence of blood in stool. It is the result of gastrointestinal hemorrhage and it may be easily seen in stool or may be identified microscopically.

Indicate ‘Yes’, if the patient has experienced this at any time from onset of this illness to presentation.

SNOMED

405729008, Hematochezia (finding)

C0018932, Hematochezia

clinical_features

presentation

SIGNS ON ADMISSION: Indicate if experienced at any time from onset of this illness to the day of presentation.

adsign_rectalbleed

radio

Rectal bleeding

1, Yes | 0, No | 99, Unknown

Gastrointestinal

This refers to bleeding originating from the rectal wall and discharged from the anus.

Indicate ‘Yes’, if the patient has experienced this at any time from onset of this illness to presentation.

SNOMED

12063002, Rectal bleeding

C0267596, Rectal bleeding

clinical_features

presentation

SIGNS ON ADMISSION: Indicate if experienced at any time from onset of this illness to the day of presentation.

adsign_lowurine

radio

Reduced urine output

1, Yes | 0, No | 99, Unknown

Genitourinary

This refers to a finding indicating that the urine production is less than 500 milliliters during a 24 hour period.

Indicate ‘Yes’, if the patient has experienced this at any time from onset of this illness to presentation.

SNOMED

167372005, 24 hour urine volume below reference range (finding)

C5933437, Reduced urine output

clinical_features

presentation

SIGNS ON ADMISSION: Indicate if experienced at any time from onset of this illness to the day of presentation.

adsign_heme

descriptive

Haematological signs

Haematology

This refers to signs and symptoms relating to the haematological system.

Indicate ‘Yes’, if the patient has experienced this at any time from onset of this illness to presentation.

1

presentation

SIGNS ON ADMISSION: Indicate if experienced at any time from onset of this illness to the day of presentation.

adsign_anaemia

radio

Anaemia

1, Yes | 0, No | 99, Unknown

Haematology

This refers to a reduction in the number of red blood cells, the amount of hemoglobin, and/or the volume of packed red blood cells. Common manifestations include pallor, fatigue, dizziness, shortness of breath, and tachycardia.

Indicate ‘Yes’, if the patient has experienced this at any time from onset of this illness to presentation.

SNOMED

271737000, Anaemia

C0002871, Anemia

clinical_features

1

presentation

SIGNS ON ADMISSION: Indicate if experienced at any time from onset of this illness to the day of presentation.

adsign_cns

descriptive

Neurological signs

Nervous system

This refers to signs and symptoms relating to the neurological system.

Indicate ‘Yes’, if the patient has experienced this at any time from onset of this illness to presentation.

1

presentation

SIGNS ON ADMISSION: Indicate if experienced at any time from onset of this illness to the day of presentation.

adsign_neckstiff

radio

Neck stiffness

1, Yes | 0, No | 99, Unknown

Nervous system

Defined as a sensation of tightness in the neck when attempting to move it, especially after a period of inactivity. Neck stiffness often involves soreness and difficulty moving the neck, especially when trying to turn the head to the side.

Indicate ‘Yes’, if the patient has experienced this at any time from onset of this illness to presentation.

SNOMED

161882006, Stiff neck (finding)

C0151315, Neck Stiffness

clinical_features

1

presentation

SIGNS ON ADMISSION: Indicate if experienced at any time from onset of this illness to the day of presentation.

adsign_hemiplegia

radio

Hemiplegia

1, Yes | 0, No | 99, Unknown

Nervous system

This refers to severe or complete loss of motor function on one side of the body; often caused by brain diseases that are localized to the cerebral hemisphere opposite to the side of weakness; less frequently, brain stem lesions; cervical spinal cord diseases, peripheral nervous system diseases, and other conditions may manifest as hemiplegia.

Indicate ‘Yes’, if the patient has experienced this at any time from onset of this illness to presentation.

SNOMED

50582007, Hemiplegia (disorder)

C0018991, Hemiplegia

clinical_features

1

presentation

SIGNS ON ADMISSION: Indicate if experienced at any time from onset of this illness to the day of presentation.

adsign_cogimpair

radio

Cognitive impairment

1, Yes | 0, No | 99, Unknown

Nervous system

This refers to diminished or impaired mental and/or intellectual function.

Indicate ‘Yes’, if the patient has experienced this at any time from onset of this illness to presentation.

SNOMED

386806002, Impaired cognition (finding)

C0338656, Impaired cognition

clinical_features

1

presentation

SIGNS ON ADMISSION: Indicate if experienced at any time from onset of this illness to the day of presentation.

adsign_neurodist

radio

Psychological disturbance

1, Yes | 0, No | 99, Unknown

Nervous system

This refers to the presence of signs or symptoms that affect an individual’s thoughts, emotions, behaviours or mental well-being. The presence of psychological disturbances should be identified through a Mental Status Examination (MSE) or equivalent tool.

Indicate ‘Yes’, if the patient has experienced this at any time from onset of this illness to presentation.

C0233395, Psychological sign or symptom

clinical_features

1

presentation

SIGNS ON ADMISSION: Indicate if experienced at any time from onset of this illness to the day of presentation.

adsign_speechdist

radio

Speech disturbance

1, Yes | 0, No | 99, Unknown

Nervous system

This refers to difficulties with speech and communication that may result from pathologies in the brain.

Indicate ‘Yes’, if the patient has experienced this at any time from onset of this illness to presentation.

SNOMED

29164008, Disturbance in speech (finding)

C0233715, Speech impairment

clinical_features

1

presentation

SIGNS ON ADMISSION: Indicate if experienced at any time from onset of this illness to the day of presentation.

adsign_agitation

radio

Agitation

1, Yes | 0, No | 99, Unknown

Nervous system

This refers to a state of excessive motor activity that is associated with mental distress or a feeling of substantial unease or inner tension. Distinguished from restlessness by the increased level of emotional distress and negative intensity of the experience. Agitation has a significant level of physical activity that is typically threatening to the self or others.

Indicate ‘Yes’, if the patient has experienced this at any time from onset of this illness to presentation.

SNOMED

24199005, Feeling agitated (finding)

C0085631, Agitation

clinical_features

1

presentation

SIGNS ON ADMISSION: Indicate if experienced at any time from onset of this illness to the day of presentation.

adsign_cerebesig

radio

Cerebellar signs

1, Yes | 0, No | 99, Unknown

Nervous system

Refers to the presence of a constellation of neurological signs typically indicate cerebellar dysfunction. Signs include dysdiadochokinesia, dysmetria, ataxia, nystagmus, intention tremor, slurred or scanning speech, hypotonia.

Indicate ‘Yes’, if the patient has experienced this at any time from onset of this illness to presentation.

C3807868, Cerebellar signs

clinical_features

1

presentation

SIGNS ON ADMISSION: Indicate if experienced at any time from onset of this illness to the day of presentation.

adsign_neurologic

radio

Other neurological abnormality

1, Yes | 0, No | 99, Unknown

Nervous system

This refers the presence of an alternative neurological abnormality not listed above.

Indicate ‘Yes’, if the patient has experienced this at any time from onset of this illness to presentation.

clinical_features

1

presentation

SIGNS ON ADMISSION: Indicate if experienced at any time from onset of this illness to the day of presentation.

adsign_neurologic_spec

text

Specify other neurological abnormality

[adsign_neurologic] = ‘1’

Nervous system

This refers the presence of another neurological abnormality not listed above.

If ‘Other’, specify neurological abnormality.

clinical_features

1

presentation

SIGNS ON ADMISSION: Indicate if experienced at any time from onset of this illness to the day of presentation.

adsign_eye

descriptive

Opthalmological signs

Nervous system

This refers to signs and symptoms relating to the eye.

Indicate ‘Yes’, if the patient experienced this between 00:00 to 24:00 on day of assessment.

presentation

SIGNS ON ADMISSION: Indicate if experienced at any time from onset of this illness to the day of presentation.

adsign_retroorbit

radio

Retro-orbital pain

1, Yes | 0, No | 99, Unknown

Nervous system

Defined as the experience of pain in the retro-orbital region (behind the eyes).

Indicate ‘Yes’, if the patient has experienced this at any time from onset of this illness to presentation.

MedDRA

10033381, Pain behind eyes

C0743724, Retro-orbital pain

clinical_features

presentation

SIGNS ON ADMISSION: Indicate if experienced at any time from onset of this illness to the day of presentation.

adsign_conjunhemor

radio

Subconjunctival haemorrhage

1, Yes | 0, No | 99, Unknown

Ocular

Defined as the accumulation of blood underneath the conjunctiva, presenting as a bright red or dark patch in the eye.

Indicate ‘Yes’, if the patient has experienced this at any time from onset of this illness to presentation.

SNOMED

78768009, Subconjunctival hemorrhage (disorder)

C0038534, Subconjunctival hemorrhage

clinical_features

presentation

SIGNS ON ADMISSION: Indicate if experienced at any time from onset of this illness to the day of presentation.

adsign_conjunctiv

radio

Conjunctivitis

1, Yes | 0, No | 99, Unknown

Ocular

Defined as inflammation of the conjunctiva

Indicate ‘Yes’, if the patient has experienced this at any time from onset of this illness to presentation.

SNOMED

9826008, Conjunctivitis (disorder)

C4011653, Conjunctivitis

clinical_features

1

presentation

SIGNS ON ADMISSION: Indicate if experienced at any time from onset of this illness to the day of presentation.

adsign_keratitis

radio

Keratitis

1, Yes | 0, No | 99, Unknown

Ocular

This refers to inflammation of the cornea of the eye.

Indicate ‘Yes’, if the patient has experienced this at any time from onset of this illness to presentation.

SNOMED

5888003, Keratitis (disorder)

C0022568, Keratitis (disorder)

clinical_features

presentation

SIGNS ON ADMISSION: Indicate if experienced at any time from onset of this illness to the day of presentation.

adsign_newvision

radio

Newly reduced visual acuity

1, Yes | 0, No | 99, Unknown

Ocular

Defined as decreased clarity or sharpness of vision.

Indicate ‘Yes’, if the patient has experienced this at any time from onset of this illness to presentation.

SNOMED

13164000, Reduced visual acuity (finding)

C0234632, Reduced visual acuity

clinical_features

1

presentation

SIGNS ON ADMISSION: Indicate if experienced at any time from onset of this illness to the day of presentation.

adsign_sunkeyes

radio

Sunken eyes

1, Yes | 0, No | 99, Unknown

Ocular

Indicate ‘Yes’, if the patient has experienced this at any time from onset of this illness to presentation.

clinical_features

presentation

SIGNS ON ADMISSION: Indicate if experienced at any time from onset of this illness to the day of presentation.

adsign_ocularoth

radio

Other opthalmological signs

1, Yes | 0, No | 99, Unknown

Ocular

This refers to other signs and symptoms relating to the eye, not specified above.

Indicate ‘Yes’, if the patient has experienced this at any time from onset of this illness to presentation.

1

presentation

SIGNS ON ADMISSION: Indicate if experienced at any time from onset of this illness to the day of presentation.

adsign_ocularoth_spec

text

Specify other opthalmological signs

Ocular

This refers to other signs and symptoms relating to the eye, not specified above.

If ‘Yes’, specify other opthalmological signs and symptoms

1

1

presentation

SIGNS ON ADMISSION: Indicate if experienced at any time from onset of this illness to the day of presentation.

adsign_paed

descriptive

Paediatric-specific signs

[demog_calcage_days]<=1825

Paediatric

1

1

presentation

SIGNS ON ADMISSION: Indicate if experienced at any time from onset of this illness to the day of presentation.

adsign_nasalflar

radio

Nasal flaring

1, Yes | 0, No | 99, Unknown

[demog_calcage_days]<=1825

Paediatric

1

presentation

SIGNS ON ADMISSION: Indicate if experienced at any time from onset of this illness to the day of presentation.

adsign_grunt

radio

Grunting

1, Yes | 0, No | 99, Unknown

[demog_calcage_days]<=1825

Paediatric

1

presentation

SIGNS ON ADMISSION: Indicate if experienced at any time from onset of this illness to the day of presentation.

adsign_ftt

radio

Failure to thrive

1, Yes | 0, No | 99, Unknown

[demog_calcage_days]<=28

Paediatric

1

presentation

SIGNS ON ADMISSION: Indicate if experienced at any time from onset of this illness to the day of presentation.

adsign_hypotonia

radio

Decreased tone / hypotonia

1, Yes | 0, No | 99, Unknown

[demog_calcage_days]<=28

Paediatric

1

1

presentation

SIGNS ON ADMISSION: Indicate if experienced at any time from onset of this illness to the day of presentation.

adsign_bulgefont

radio

Bulging fontanelle

1, Yes | 0, No | 99, Unknown

[demog_calcage_days]<=28

Paediatric

1

1

presentation

SIGNS ON ADMISSION: Indicate if experienced at any time from onset of this illness to the day of presentation.

adsign_otherdesc

descriptive

Other signs

Other

1

1

presentation

SIGNS ON ADMISSION: Indicate if experienced at any time from onset of this illness to the day of presentation.

adsign_unlisted

list

Other sign(s)

1, Yes | 0, No | 99, Unknown

conditions_Symptoms

Other

This refers to other signs and symptoms, not specified above.

Indicate other signs and symptoms, not specified above, the patient has exeprienced at any time from onset of this illness to presentation.

clinical_features

1

1

presentation

PREGNANCY PRESENTATION

preg_pregnant

radio

Pregnant

1, Yes | 0, No | 99, Unknown

[demog_sex]=’2’ and [demog_calcage_days]>=4380

This refers to women who reports to be pregnant at presentation and/or have had a positive pregnancy test in recent days prior to presentation.

Indicate ‘Yes’, if the patient is pregnant at presentation. If the patient is of fertile age with no negative pregnancy test select ‘Unknown’.

SNOMED

77386006, Pregnant (finding)

C0549206, Pregnant

risk_factor_demo

1

1

1

1

1

1

1

1

1

1

presentation

PREGNANCY PRESENTATION

preg_postpartum

radio

Post-partum (within 6 weeks of delivery)

1, Yes | 0, No | 99, Unknown

[demog_sex]=’2’ and [preg_pregnant]=’0’ and [demog_calcage_days]>=4380

This refers to the temporal period relating to mother from completion of labour until six weeks post-delivery.

Indicate ‘Yes’, if the patient is in post-partum period (within 6 weeks of delivery).

SNOMED

86569001, Postpartum state (finding)

C0086839, Postpartum Period

risk_factor_demo

1

1

1

1

1

1

1

1

1

1

presentation

PREGNANCY PRESENTATION

preg_formdesc

descriptive

Please complete the Pregnancy Form with information from the most recent pregnancy.

[preg_postpartum]=1

1

1

1

presentation

PREGNANCY PRESENTATION

preg_geswek

number

Gestational weeks at presentation

number

0

45

[preg_pregnant] = ‘1’

This refers to the gestational age of the foetus (written in weeks). It can be calculated from the woman’s last menstrual period (LMP) or calculated using the best obstetrical estimated due date (EDD) based on the following formula: Gestational Age = (280 - (EDD - Reference Date)). The reference date is the date in which you are trying to determine the gestational age.

Indicate the estimated gestational age of the foetus (in weeks).

SNOMED

57036006 |Fetal gestational age (observable entity)|

CL1385889, Gestational weeks

1

1

1

1

1

1

1

1

1

1

presentation

PREGNANCY PRESENTATION

preg_recent1

radio

Was patient pregnant either within <=21 days of symptoms onset or within 22-42 days from admission

1, Yes | 0, No | 99, Unknown

[preg_postpartum] = ‘1’

If non-pregnant currently, this refers to whether the patient was pregnant within 21 days of onset of symptoms.

Indicate ‘Yes, if the patient was pregnant within 21 days of onset of symptoms.

1

1

presentation

PREGNANCY PRESENTATION

preg_delvdate

date_dmy

Delivery date

date_dmy

[preg_postpartum] = ‘1’

This refers to the actual date of delivery.

Enter the date of delivery in DD/MM/YYYY format.

SNOMED

386216000, Human parturition, function (observable entity)

1

1

1

1

1

1

presentation

PREGNANCY PRESENTATION

preg_bboutc

radio

Pregnancy outcome

1, Livebirth (even if infant died after birth) | 2, Miscarriage (<22 weeks) | 3, Termination by choice | 4, Termination - ultrasound abnormality | 5, Termination - other/unknown reason | 6, Stillbirth (intra-uterine / intrapartum death from 22 gest weeks) | 7, Ectopic pregnancy | 99, Unknown

[preg_postpartum] = ‘1’

This refers to the outcome of previous conception and ensuing pregnancy.

Indicate the outcome of the previous pregnancy.

SNOMED

1, 281050002 Livebirth (finding)| 2, 237364002 Stillbirth (finding) | 4, 17369002 Miscarriage (disorder) | 3, 386639001 Termination of pregnancy (procedure) |

C0032972, Pregnancy Outcome | 1, C0419373 Livebirth | 2, C0595939 Stillbirth | 4, C4552766 Miscarriage | 3, C0392535 Termination of pregnancy

1

1

1

1

1

1

1

presentation

PREGNANCY PRESENTATION

preg_brefed

radio

Breastfeeding

1, Yes-currently breastfeeding | 2, Yes-breastfeeding discontinued | 0, No | 99, Unknown

[preg_postpartum] = ‘1’

Provision of human breast milk to the infant, either directly at the breast or expressed, regardless of exclusivity.

1

1

1

presentation

PREGNANCY PRESENTATION

preg_brefedduration

number

How long did breastfeeding last? (weeks)

number

0

[preg_postpartum] = ‘1’

Total duration from initiation of breastfeeding to complete cessation, recorded in completed weeks.

1

1

1

presentation

PREGNANCY PRESENTATION

pregdet_labour

radio

Is the patient in labour at presentation?

1, Yes | 0, No | 99, Unknown

[preg_pregnant] = ‘1’

1

1

1

presentation

PREGNANCY PRESENTATION

preg_bbtest

radio

Baby tested for mother’s infection of interest

1, Yes | 0, No | 99, Unknown

[preg_postpartum] = ‘1’

This refers to testing the baby for the mother’s infection of interest.

Indicate ‘Yes’ if the baby was tested for the mother’s infection of interest.

1

1

1

1

1

1

presentation

PREGNANCY PRESENTATION

preg_bbresl

radio

If yes: specify test result from mother’s infection of interest

1, Positive | 0, Negative | 99, Unknown

[preg_bbtest] = ‘1’

This refers to the result of testing the baby for the mother’s infection of interest.

Indicate the test result.

1

1

1

1

1

1

presentation

INFANT: LESS THAN 12 MONTHS OLD

infa_neonate

descriptive

The patient is a neonate. Please do not forget to complete the neonate-specific form.

[demog_calcage_days]<=28

1

1

presentation

INFANT: LESS THAN 12 MONTHS OLD

infa_brtwei

number

Birth weight

number

0

[demog_calcage_days]<=365

This refers to the first weight of a newborn obtained after birth.

Indicate the birth weight.

SNOMED

47340003, Birth weight (finding)

C0005612, Birth weight

1

1

1

1

1

1

1

presentation

INFANT: LESS THAN 12 MONTHS OLD

infa_brtwei_units

radio

Birth weight (select units)

1, g | 2, lb

units

[demog_calcage_days]<=365

SNOMED

47340003, Birth weight (finding)

C0005612, Birth weight

1

1

1

1

1

1

1

presentation

INFANT: LESS THAN 12 MONTHS OLD

infa_brtwei_g

number

Birth weight (g)

number

0

[demog_calcage_days]<=365

This refers to the first weight of a newborn obtained after birth.

Indicate the birth weight in kilograms (kg).

SNOMED

364589006, Birth weight (observable entity)

1

1

1

1

1

1

presentation

INFANT: LESS THAN 12 MONTHS OLD

infa_brtwei_lb

number

Birth weight (lb)

number

0

[demog_calcage_days]<=365

This refers to the first weight of a newborn obtained after birth.

Indicate the birth weight in pounds (lb).

SNOMED

364589006, Birth weight (observable entity)

C0005612, Birth weight

1

1

1

1

1

1

presentation

INFANT: LESS THAN 12 MONTHS OLD

infa_outcome

radio

Preterm birth (< 37wk GA)

1, Yes | 0, No | 99, Unknown

[demog_calcage_days]<=365

This refers to the gestational age (GA) of the infant at delivery. Pre-term refers to an infant born before 37 weeks and 0 days gestational age.

Indicate ‘Term birth’ if gestational age (GA) at delivery >= 37 weeks and ‘Preterm birth’ if GA at delivery < 37 weeks.

SNOMED

1, 21243004 |Term birth of newborn (finding)| 2, 367494004 |Premature birth of newborn (finding)|

1, C0233324 Term birth| 2, C4011994 Preterm birth

1

1

1

1

1

1

1

presentation

INFANT: LESS THAN 12 MONTHS OLD

infa_brefed

radio

Breastfed

1, Yes-currently breastfeeding | 2, Yes-breastfeeding discontinued | 0, No | 99, Unknown

[demog_calcage_days]<=730

This refers to the current breastfeeding regimen for the infant.

Indicate the breastfeeding status of infant.

SNOMED

1, 1260078007 | Maternal breastfeeding (finding) | 2, 169746009 | Breastfeeding stopped (finding) |

C0006147, Breast feeding

1

1

1

1

1

1

presentation

INFANT: LESS THAN 12 MONTHS OLD

infa_brefedduration

number

How long did breastfeeding last? (weeks)

number

0

260

[infa_brefed] = ‘2’

This refers to the duration of breastfeeding, in weeks, if breastfeeding was discontinued.

Indicate the duration of breastfeeding, in weeks, if breastfeeding was discontinued.

SNOMED

1, 1260078007 | Maternal breastfeeding (finding) | 2, 169746009 | Breastfeeding stopped (finding) |

C0006147, Breast feeding

1

1

presentation

INFANT: LESS THAN 12 MONTHS OLD

infa_aprvac

radio

Vaccinations appropriate for age/country

1, Yes | 0, No | 99, Unknown

[demog_calcage_days]<=730

This refers to the vaccination status according to the age of the infant and country-specific recommendations.

Indicate ‘Yes’, if the infant is appropriately vaccinated for age with respect to country-specific recommendations.

SNOMED

713404003, Vaccination given (situation)

C0042196, Vaccination

1

1

1

1

daily

DAILY ASSESSMENT

daily_date

date_dmy

DATE OF ASSESSMENT

date_dmy

today

This indicates the day of data collection and sampling (may not be the date of completion). This may be retrospective information at the time of discharge (transfer to other hospital or dead in hospital).

Enter the date of assessment. (Use the format DD/MM/YYYY)

1

1

1

1

1

1

1

1

1

daily

DAILY ASSESSMENT

asses_lvlcare

radio

Current level of care

1, Outpatient | 2, Admitted to normal ward for isolation only | 3, Admitted to normal ward for clinical care | 4, High dependency | 5, Intensive care admission

Refers to the level of care on date of assessment.

Select the highest level of care on the date of assessment.

SNOMED

SNOMED

C4545175, Outpatient care management | C0583229, Admission to ward | C1301858, Admission to high dependency unit | C0583239, Admission to intensive care unit

1

1

1

1

1

1

1

1

1

daily

VITAL SIGNS & ASSESSMENTS: Record the value furthest from normal range between 00:00 to 24:00 on day of assessment.

vital_dailydata

radio

Enter Vital Signs data for this date?

1, Yes | 0, No

This refers to vital signs data recorded for this date.

Indicate ‘Yes’, if you want to record vital sign data for this day of assessment. If ‘Yes’, for the following questions unless otherwise specified, Record the value furthest from the normal physiological range recorded between 00:00 and 24:00 hours on day of assessment. Results that were rejected by the clinical team should not be included.

SNOMED

SNOMED

C0150404, Taking vital signs

1

1

1

1

1

1

1

1

1

daily

VITAL SIGNS & ASSESSMENTS: Record the value furthest from normal range between 00:00 to 24:00 on day of assessment.

vital_highesttem

number

Highest temperature

number

32

106.7

[vital_dailydata]=’1’

Refers to the highest peripheral body temperature (rectal if <3 months) between 00:00 and 24:00 on day of assessment.

Enter the highest peripheral body temperature recorded between 00:00 and 24:00 on day of assessment.

clinical_features

1

1

1

1

1

1

1

1

1

daily

VITAL SIGNS & ASSESSMENTS: Record the value furthest from normal range between 00:00 to 24:00 on day of assessment.

vital_highesttem_units

radio

Highest temperature (select units)

1, °C | 2, °F

units

[vital_dailydata]=’1’

clinical_features

1

1

1

1

1

1

1

1

daily

VITAL SIGNS & ASSESSMENTS: Record the value furthest from normal range between 00:00 to 24:00 on day of assessment.

vital_highesttem_c

number

Highest temperature (°C)

number

32

41.5

[vital_dailydata]=’1’

Refers to the highest peripheral body temperature (rectal if <3 months) between 00:00 and 24:00 on day of assessment.

Enter the highest peripheral body temperature (°C) recorded between 00:00 and 24:00 on day of assessment.

SNOMED

SNOMED

clinical_features

1

1

1

1

1

1

1

daily

VITAL SIGNS & ASSESSMENTS: Record the value furthest from normal range between 00:00 to 24:00 on day of assessment.

vital_highesttem_f

number

Highest temperature (°F)

number

89.5

106.7

[vital_dailydata]=’1’

Refers to the highest peripheral body temperature (rectal if <3 months) between 00:00 and 24:00 on day of assessment.

Enter the highest peripheral body temperature (°F) recorded between 00:00 and 24:00 on day of assessment.

SNOMED

SNOMED

clinical_features

1

1

1

1

1

1

1

daily

VITAL SIGNS & ASSESSMENTS: Record the value furthest from normal range between 00:00 to 24:00 on day of assessment.

vital_hr

number

HR (bpm)

number

0

299

[vital_dailydata]=’1’

Refers to heart rate measured in beats per minute. This may be measured manually or by electronic monitoring.

Enter the heart rate measured in beats per minute. Record the value furthest from normal range between 00:00 to 24:00 on day of assessment.

SNOMED

SNOMED

clinical_features

1

1

1

1

1

1

1

1

1

1

daily

VITAL SIGNS & ASSESSMENTS: Record the value furthest from normal range between 00:00 to 24:00 on day of assessment.

vital_rr

number

RR (breaths/min)

number

0

120

[vital_dailydata]=’1’

Refers to respiratory rate in breaths per minute. Manual rather than electronic measurement is preferred where possible (this is achieved by counting the number of breaths for one minute, counting how many times the chest rises within this time period). If both abnormal low and high rate observed, record the abnormally high rate.

Enter the respiratory rate measured in breaths per minute. Record the value furthest from normal range between 00:00 to 24:00 on day of assessment. If both abnormal low and high rate observed, record the abnormally high rate.

SNOMED

SNOMED

clinical_features

1

1

1

1

1

1

1

1

1

daily

VITAL SIGNS & ASSESSMENTS: Record the value furthest from normal range between 00:00 to 24:00 on day of assessment.

vital_systolicbp

number

Systolic BP (mmHg)

number

0

299

[vital_dailydata]=’1’

This refers to the systolic blood pressure from the observation with the lowest mean arterial pressure (if mean arterial pressure has not been calculated, report the measurement with lowest systolic blood pressure). For example, if the blood pressure is 120/85 mmHg, enter 120 in the section marked ‘systolic BP’.

Enter the systolic blood pressure measured in millimetres of mercury (mmHg). Record the systolic blood pressure from the observation with the lowest mean arterial pressure (MAP) (if mean arterial pressure has not been calculated, report the measurement with lowest systolic blood pressure) that occurred between 00:00 to 24:00 on day of assessment.

SNOMED

SNOMED

clinical_features

1

1

1

1

1

1

1

1

1

1

1

daily

VITAL SIGNS & ASSESSMENTS: Record the value furthest from normal range between 00:00 to 24:00 on day of assessment.

vital_diastolicbp

number

Diastolic BP (mmHg)

number

0

200

[vital_dailydata]=’1’

This refers to the diastolic blood pressure from the observation with the lowest mean arterial pressure (if mean arterial pressure has not been calculated, report the measurement with lowest systolic blood pressure). For example, if the blood pressure is 120/85 mmHg, enter 85 in the section marked ‘diastolic BP’.

Enter the diastolic blood pressure measured in millimetres of mercury (mmHg). Record the diastolic blood pressure from the observation with the lowest mean arterial pressure (MAP) (if mean arterial pressure has not been calculated, report the measurement with lowest systolic blood pressure) that occurred between 00:00 to 24:00 on day of assessment.

SNOMED

SNOMED

clinical_features

1

1

1

1

1

1

1

1

1

1

1

daily

VITAL SIGNS & ASSESSMENTS: Record the value furthest from normal range between 00:00 to 24:00 on day of assessment.

vital_meanbp

number

Mean arterial blood pressure (mmHg)

number

0

200

[vital_dailydata]=’1’

Mean arterial blood pressure (MAP) may be directly measured (via intra-arterial catheter) or be approximated without an invasive procedure using the following formula: diastolic pressure plus 1/3 of the pulse pressure, where pulse pressure is systolic pressure - diastolic pressure.

Enter the lowest recorded MAP that occurred between 00:00 to 24:00 on day of assessment.

SNOMED

SNOMED

clinical_features

1

1

1

1

1

1

1

daily

VITAL SIGNS & ASSESSMENTS: Record the value furthest from normal range between 00:00 to 24:00 on day of assessment.

vital_spo2room

number

Oxygen saturation at room air (no oxygen support) (%)

number

0

100

[vital_dailydata]=’1’

This refers to the measurement of the ratio of oxygenated hemoglobin to total hemoglobin in the blood, measured at room air with no oxygen support.

Indicate the measurement of oxygen saturation at room air with no oxygen support.

clinical_features

1

1

1

1

1

1

1

1

daily

VITAL SIGNS & ASSESSMENTS: Record the value furthest from normal range between 00:00 to 24:00 on day of assessment.

vital_spo2roomhow

radio

How was oxygen saturation at room air measured?

1, Pulse Oximetry | 2, Arterial blood gas measurement | 88, Other | 99, Unknown

[vital_dailydata]=’1’

This refers to the method of measurement of oxygen saturation.

Select the most appropriate option which represents the method of measurement of oxygen saturation.

clinical_features

1

1

daily

VITAL SIGNS & ASSESSMENTS: Record the value furthest from normal range between 00:00 to 24:00 on day of assessment.

vital_o2supp

radio

Supplemental oxygen?

1, Yes | 0, No | 99, Unknown

[vital_dailydata]=’1’

This refers to the delivery of supplemental oxygen at the time of the above, lowest SpO2 (%), recording.

Indicate ‘Yes’, if the FiO2 was measured along-side the lowest oxygen saturation (SpO2) reported above.

SNOMED

SNOMED

clinical_features

1

1

1

1

1

1

1

1

1

daily

VITAL SIGNS & ASSESSMENTS: Record the value furthest from normal range between 00:00 to 24:00 on day of assessment.

vital_o2supp_type

radio

Type of supplemental oxygen?

1, Nasal Prongs | 2, Face mask | 3, High flow nasal oxygen | 4, Non-invasive ventilation | 5, Invasive ventilation | 6, ECMO / ECLS | 99, Unknown

[vital_o2supp]=’1’

This refers to the type / mode of delivery for supplemental oxygen at the time of the above, lowest SpO2 (%), recording.

Select the most approproate option which represents the type / mode of delivery for supplemental oxygen at the time of the above, lowest SpO2 (%), recording.

SNOMED

SNOMED

C0445087, Nasal prongs | C1299377, Oxygen administration by mask | C4761117, High-flow nasal cannula oxygen therapy | C1997883, Noninvasive Ventilation | C0015357, Extracorporeal Membrane Oxygenation

clinical_features

1

1

1

1

1

1

1

1

daily

VITAL SIGNS & ASSESSMENTS: Record the value furthest from normal range between 00:00 to 24:00 on day of assessment.

vital_o2supp_spo2

number

Oxygen saturation with supplemental oxygen (%)

number

0

100

[vital_o2supp]=’1’

This refers to the oxygen saturation, that may be measured by pulse oximetry or by arterial blood gas analysis. It is irrespective of ventilation or supplemental oxygen requirement.

Enter the percentage oxygen saturation. Record the value furthest from normal range between 00:00 to 24:00 on day of assessment.

SNOMED

SNOMED

clinical_features

1

1

1

1

1

1

1

1

1

1

1

daily

VITAL SIGNS & ASSESSMENTS: Record the value furthest from normal range between 00:00 to 24:00 on day of assessment.

vital_o2supp_spo2how

radio

How was oxygen saturation with supplemental oxygen measured?

1, Pulse Oximetry | 2, Arterial blood gas measurement | 88, Other | 99, Unknown

[vital_o2supp]=’1’

This refers to the method of measurement of oxygen saturation.

Select the most appropriate option which represents the method of measurement of oxygen saturation.

1

1

daily

VITAL SIGNS & ASSESSMENTS: Record the value furthest from normal range between 00:00 to 24:00 on day of assessment.

vital_fio2spo2

number

FiO2 at time of lowest SpO2

number

0

100

[vital_o2supp]=’1’

This refers to the measured fraction of inspired oxygen (FiO2) delivered at the time of lowest oxygen saturation (%) recording.

Enter the FiO2 that was measured along-side the lowest oxygen saturation (SpO2) reported above. FiO2 can be reported as either a fraction or a percentage. Note that 0.21 and 21% are equivalent to the FiO2 of room-air.

SNOMED

SNOMED

C0428648, Inspired oxygen concentration

clinical_features

1

1

1

1

1

1

1

1

1

1

1

daily

VITAL SIGNS & ASSESSMENTS: Record the value furthest from normal range between 00:00 to 24:00 on day of assessment.

vital_fio2spo2_units

radio

FiO2 at time of lowest SpO2 (select units)

1, Fraction, 0.21-1.0 | 2, %, 21-100 | 3, Highest L/min

units

[vital_o2supp]=’1’

SNOMED

SNOMED

C0428648, Inspired oxygen concentration

clinical_features

1

1

1

1

1

1

1

1

1

1

daily

VITAL SIGNS & ASSESSMENTS: Record the value furthest from normal range between 00:00 to 24:00 on day of assessment.

vital_fio2spo2_02110

number

FiO2 at time of lowest SpO2 (Fraction, 0.21-1.0)

number

0.21

1

[vital_o2supp]=’1’

This refers to the measured fraction of inspired oxygen (FiO2) delivered at the time of lowest oxygen saturation (%) recording.

Enter the FiO2 (0.21-1.0) that was measured along-side the lowest oxygen saturation (SpO2) reported above. 0.21 is equivalent to the FiO2 of room-air.

SNOMED

SNOMED

C0428648, Inspired oxygen concentration

clinical_features

1

1

1

1

1

1

1

1

1

1

daily

VITAL SIGNS & ASSESSMENTS: Record the value furthest from normal range between 00:00 to 24:00 on day of assessment.

vital_fio2spo2_pcnt

number

FiO2 at time of lowest SpO2 (%, 21-100)

number

21

100

[vital_o2supp]=’1’

This refers to the measured fraction of inspired oxygen (FiO2) delivered at the time of lowest oxygen saturation (%) recording.

Enter the FiO2 (21-100%) that was measured along-side the lowest oxygen saturation (SpO2) reported above. 21% is equivalent to the FiO2 of room-air.

SNOMED

SNOMED

C0428648, Inspired oxygen concentration

clinical_features

1

1

1

1

1

1

1

1

1

1

daily

VITAL SIGNS & ASSESSMENTS: Record the value furthest from normal range between 00:00 to 24:00 on day of assessment.

vital_fio2spo2_ltr

number

FiO2 at time of lowest SpO2 (Highest L/min)

number

0

100

[vital_o2supp]=’1’

This refers to the measured fraction of inspired oxygen (FiO2) delivered at the time of lowest oxygen saturation (%) recording.

Enter the FiO2 (L/min) that was measured along-side the lowest oxygen saturation (SpO2) reported above.

SNOMED

SNOMED

C0428648, Inspired oxygen concentration

clinical_features

1

1

1

1

1

1

1

1

1

1

daily

VITAL SIGNS & ASSESSMENTS: Record the value furthest from normal range between 00:00 to 24:00 on day of assessment.

vital_capillaryr

radio

Capillary refill time >2 seconds

1, Yes | 0, No | 99, Unknown

[vital_dailydata]=’1’

Capillary refill time is measured by pressing on the sternum for five seconds with a finger or thumb until the underlying skin turns white and then noting the time in seconds needed for the colour to return once the pressure is released.

Indicate ‘Yes’, if the capillary refill time was greater than 2 seconds at any time between 00:00 to 24:00 on day of assessment.

SNOMED

SNOMED

clinical_features

1

1

1

1

1

1

1

1

1

1

daily

VITAL SIGNS & ASSESSMENTS: Record the value furthest from normal range between 00:00 to 24:00 on day of assessment.

vital_avpu

radio

ACVPU

1, Alert | 5, Confusion | 2, Verbal | 3, Pain | 4, Unresponsive

[vital_dailydata]=’1’

Refers to the scoring system for consciousness: alert; confused (new-onset or worsening); responding to voice; responding to pain; unresponsive.

Select the single option corresponding to the least responsive condition of the patient between 00:00 to 24:00 on day of assessment. If the patient is being sedated on the day of assessment record the value before the sedation.

SNOMED

SNOMED

clinical_features

1

1

1

1

1

1

1

1

1

daily

VITAL SIGNS & ASSESSMENTS: Record the value furthest from normal range between 00:00 to 24:00 on day of assessment.

vital_gcs

number

Glasgow Coma Score (GCS / 15)

number

3

15

[vital_dailydata]=’1’

The Glasgow Coma Scale is a scoring system for consciousness. It is scored out of 15 and requires an assessment of responsiveness to stimulus. Glasgow Coma Score: https://www.glasgowcomascale.org/downloads/GCS-Assessment-Aid-English.pdf?v=3

Enter the lowest GCS recorded between 00:00 to 24:00 on day of assessment. For intubated patients and patients with a non-fenestrated tracheostomy, give 1 point for the voice component and calculate the total as usual. Suffixes such as ‘t’ for tracheostomy cannot be entered on to the database. If the patient is sedated on the day of assessment these parameters should correspond to the values observed before sedation.

SNOMED

SNOMED

clinical_features

1

1

1

1

1

1

1

1

1

1

1

1

daily

VITAL SIGNS & ASSESSMENTS: Record the value furthest from normal range between 00:00 to 24:00 on day of assessment.

vital_rass

number

Richmond Agitation-Sedation Scale (RASS)

number

-5

4

[vital_dailydata]=’1’

Richmond Agitation-Sedation Scale (RASS) is a medical scale used to measure the agitation or sedation level of a person. It ranges from -5 to +4, where 0 refers to an ‘Alert and calm’ patient that spontaneously pays attention.

If performed, enter the lowest value (between -5 and +4) between 00:00 to 24:00 hours on day of assessment.

C4720839, Richmond Agitation-Sedation Scale

clinical_features

1

1

daily

VITAL SIGNS & ASSESSMENTS: Record the value furthest from normal range between 00:00 to 24:00 on day of assessment.

vital_urineflow

number

Urine output (mL/day)

number

0

20000

[vital_dailydata]=’1’

This refers to the amount of urine the patient has produced over a 24-hour period, specifically the date of assessment. This may be measured e.g. via use of a urinary catheter or estimated.

Record the patient’s urine output (in ml/24hours) over the day of assessment

SNOMED

SNOMED

clinical_features

1

1

1

1

1

1

1

daily

SYMPTOMS: Indicate if experienced between 00:00 to 24:00 on day of assessment.

sympt_dailydata

radio

Enter patient reported symptoms data for this date?

1, Yes | 0, No

This refers to signs and symptoms recorded o this date.

Indicate ‘Yes’, if you want to record signs and symptoms data for this day of assessment.

SNOMED

SNOMED

C0037088, Signs and Symptoms

1

1

1

1

1

1

daily

SYMPTOMS: Indicate if experienced between 00:00 to 24:00 on day of assessment.

sympt_sys

descriptive

Systemic / general symptoms

[sympt_dailydata]=’1’

Systemic/General

This refers to systemic / general / non-specific signs and symptoms

Indicate ‘Yes’, if the patient experienced this between 00:00 to 24:00 on day of assessment.

1

1

1

1

1

1

daily

SYMPTOMS: Indicate if experienced between 00:00 to 24:00 on day of assessment.

sympt_fever

radio

Fever

1, Yes | 0, No | 99, Unknown

[sympt_dailydata]=’1’

Systemic/General

Defined as the sensation of elevated body temperature without formal measurement, or a measured body temperature greater or equal to 38-degrees Celsius (38°C) or 100.4-Fahrenheit (100.4°F).

Indicate ‘Yes’, if the patient experienced this between 00:00 to 24:00 on day of assessment.

SNOMED

SNOMED

C0015967, Fever

clinical_features

1

1

1

1

1

1

daily

SYMPTOMS: Indicate if experienced between 00:00 to 24:00 on day of assessment.

sympt_rigchill

radio

Chills or rigors

1, Yes | 0, No | 99, Unknown

[sympt_dailydata]=’1’ and [initial_assessment_arm_1][demog_calcage_days]>=28

Systemic/General

Defined as severe chills with violent shivering. A rigor is an episode of shaking or exaggerated shivering which can occur with a high fever.

Indicate ‘Yes’, if the patient experienced this between 00:00 to 24:00 on day of assessment.

1

1

1

1

daily

SYMPTOMS: Indicate if experienced between 00:00 to 24:00 on day of assessment.

sympt_nightsweat

radio

Night sweats

1, Yes | 0, No | 99, Unknown

[sympt_dailydata]=’1’ and [initial_assessment_arm_1][demog_calcage_days]>=365

Systemic/General

This refers to perspiration experienced nocturnally that is unrelated to environmental temperature.

Indicate ‘Yes’, if the patient experienced this between 00:00 to 24:00 on day of assessment.

1

daily

SYMPTOMS: Indicate if experienced between 00:00 to 24:00 on day of assessment.

sympt_coldtsweat

radio

Cold sweats

1, Yes | 0, No | 99, Unknown

[sympt_dailydata]=’1’ and [initial_assessment_arm_1][demog_calcage_days]>=28

Systemic/General

This refers to sweats accompanied by sensation of feeling cold, different from sweats caused by heat or exertion.

Indicate ‘Yes’, if the patient experienced this between 00:00 to 24:00 on day of assessment.

1

daily

SYMPTOMS: Indicate if experienced between 00:00 to 24:00 on day of assessment.

sympt_excesssweat

radio

Excessive sweating (hyperhidrosis)

1, Yes | 0, No | 99, Unknown

[sympt_dailydata]=’1’

Systemic/General

This refers to excessive sweating that is not always related to fever, heat exposure or vigorous exercise.

Indicate ‘Yes’, if the patient experienced this between 00:00 to 24:00 on day of assessment.

1

daily

SYMPTOMS: Indicate if experienced between 00:00 to 24:00 on day of assessment.

sympt_fatigue

radio

Fatigue / malaise / lethargy

1, Yes | 0, No | 99, Unknown

[sympt_dailydata]=’1’ and [initial_assessment_arm_1][demog_calcage_days]>=365

Systemic/General

This refers to a constellation of non-specific sensations: the feeling of tiredness characterised by a lack of energy or motivation; general discomfort or uneasiness; disinterestedness, listlessness, and indifference, resulting in difficulty performing simple tasks or concentrating.

Indicate ‘Yes’, if the patient experienced this between 00:00 to 24:00 on day of assessment.

SNOMED

SNOMED

C0015672, Fatigue | C0231218, Malaise | C0023380 Lethargy

clinical_features

1

1

1

1

1

1

1

1

daily

SYMPTOMS: Indicate if experienced between 00:00 to 24:00 on day of assessment.

sympt_restlessne

radio

Restlessness

1, Yes | 0, No | 99, Unknown

[sympt_dailydata]=’1’

Systemic/General

This refers to a state of unease, characterised by an inability to rest or relax, diffuse motor activity with limited control, nonproductive or disorganized behaviour, and subjective distress.

Indicate ‘Yes’, if the patient experienced this between 00:00 to 24:00 on day of assessment.

SNOMED

SNOMED

C3887611, Restlessness

clinical_features

1

1

1

daily

SYMPTOMS: Indicate if experienced between 00:00 to 24:00 on day of assessment.

sympt_weak

radio

Weakness

1, Yes | 0, No | 99, Unknown

[sympt_dailydata]=’1’

Systemic/General

This refers to a decrease in muscle strength.

Indicate ‘Yes’, if the patient experienced this between 00:00 to 24:00 on day of assessment.

SNOMED

13791008

clinical_features

1

1

daily

SYMPTOMS: Indicate if experienced between 00:00 to 24:00 on day of assessment.

sympt_weight

radio

Weight loss

1, Yes | 0, No | 99, Unknown

[sympt_dailydata]=’1’

Systemic/General

This refers to reduction in total body weight (patient-reported or objectively measured) that has occurred since the onset of this illness and has been unintentional or not attributable to active dieting, exercise or dedicated medication based weight-loss interventions.

Indicate ‘Yes’, if the patient experienced this between 00:00 to 24:00 on day of assessment.

SNOMED

SNOMED

C2363736 Unintentional Weight loss

clinical_features

1

1

1

daily

SYMPTOMS: Indicate if experienced between 00:00 to 24:00 on day of assessment.

sympt_anosmia

radio

Loss of smell (anosmia)

1, Yes | 0, No | 99, Unknown

[sympt_dailydata]=’1’

Systemic/General

This refers to patient reported and/or clinician-diagnosed inability of the patient to perceive odours

Indicate ‘Yes’, if the patient experienced this between 00:00 to 24:00 on day of assessment.

SNOMED

SNOMED

C0003126, Anosmia

clinical_features

1

daily

SYMPTOMS: Indicate if experienced between 00:00 to 24:00 on day of assessment.

sympt_ageusia

radio

Loss of taste (ageusia)

1, Yes | 0, No | 99, Unknown

[sympt_dailydata]=’1’

Systemic/General

This refers to patient reported and/or clinician-diagnosed loss of taste function of the tongue.

Indicate ‘Yes’, if the patient experienced this between 00:00 to 24:00 on day of assessment.

SNOMED

SNOMED

C2364111, Ageusia

clinical_features

1

daily

SYMPTOMS: Indicate if experienced between 00:00 to 24:00 on day of assessment.

sympt_dizzy

radio

Feeling dizzy / faint

1, Yes | 0, No | 99, Unknown

[sympt_dailydata]=’1’ and [initial_assessment_arm_1][demog_calcage_days]>=1825

Systemic/General

This refers to the subjective feeling of light-headedness or dizziness which may precede an episode of syncope or a sensation of unsteadiness, spinning or rocking.

Indicate ‘Yes’, if the patient experienced this at any time during the date of assessment.

SNOMED

SNOMED

C0581879, Felt faint

clinical_features

1

1

1

1

daily

SYMPTOMS: Indicate if experienced between 00:00 to 24:00 on day of assessment.

sympt_myalgia

radio

Muscle aches (myalgia)

1, Yes | 0, No | 99, Unknown

[sympt_dailydata]=’1’ and [initial_assessment_arm_1][demog_calcage_days]>=365

Systemic/General

This refers to pain localised to a muscle or group of muscles.

Indicate ‘Yes’, if the patient experienced this at any time during the date of assessment.

SNOMED

SNOMED

C0231528, Myalgia

clinical_features

1

1

1

1

1

1

daily

SYMPTOMS: Indicate if experienced between 00:00 to 24:00 on day of assessment.

sympt_myalgia_scal

number

Myalgia intensity (Numeric Pain Rating Scale)

number

1

10

[sympt_myalgia]=’1’

1

daily

SYMPTOMS: Indicate if experienced between 00:00 to 24:00 on day of assessment.

sympt_jointswell

radio

Joint swelling

1, Yes | 0, No | 99, Unknown

[sympt_dailydata]=’1’

Systemic/General

Defined as the buildup of fluid in the soft tissue SURROUNDING the joint or in the joint itself

Indicate ‘Yes’, if the patient has experienced this at any time from onset of this illness to presentation.

SNOMED

271771009, Joint swelling

clinical_features

1

1

daily

SYMPTOMS: Indicate if experienced between 00:00 to 24:00 on day of assessment.

sympt_jointswell_site

checkbox

Site where joint swelling occurred

1, Shoulder | 2, Elbow | 3, Wrist | 4, Small joints of hand | 5, Knee | 6, Ankle |7, Small joints of foot | 88, Other

[sympt_jointswell]= ‘1’

1

1

daily

SYMPTOMS: Indicate if experienced between 00:00 to 24:00 on day of assessment.

sympt_jointswell_site_shoulder

radio

How many shoulder joints are affected?

1, 1 | 2, 2 | 99, Unknown

[sympt_jointswell_site(1)]=’1’

Systemic/General

1

daily

SYMPTOMS: Indicate if experienced between 00:00 to 24:00 on day of assessment.

sympt_jointswell_site_elbow

radio

How many elbow joints are affected?

1, 1 | 2, 2 | 99, Unknown

[sympt_jointswell_site(2)]=’1’

Systemic/General

1

daily

SYMPTOMS: Indicate if experienced between 00:00 to 24:00 on day of assessment.

sympt_jointswell_site_wrist

radio

How many wrist joints are affected?

1, 1 | 2, 2 | 99, Unknown

[sympt_jointswell_site(3)]=’1’

Systemic/General

1

daily

SYMPTOMS: Indicate if experienced between 00:00 to 24:00 on day of assessment.

sympt_jointswell_site_knee

radio

How many knee joints are affected?

1, 1 | 2, 2 | 99, Unknown

[sympt_jointswell_site(5)]=’1’

Systemic/General

1

daily

SYMPTOMS: Indicate if experienced between 00:00 to 24:00 on day of assessment.

sympt_jointswell_site_ankle

radio

How many ankle joints are affected?

1, 1 | 2, 2 | 99, Unknown

[sympt_jointswell_site(6)]=’1’

Systemic/General

1

daily

SYMPTOMS: Indicate if experienced between 00:00 to 24:00 on day of assessment.

sympt_jointswell_site_foot

number

How many small joints of the foot are affected?

number

1

14

[sympt_jointswell_site(7)]=’1’

Systemic/General

1

daily

SYMPTOMS: Indicate if experienced between 00:00 to 24:00 on day of assessment.

sympt_jointswell_hand

checkbox

Small joints of hand

1, MCP (metacarpophalangeal) joint | 2, PIP (proximal interphalangeal) joint | 3, DIP (distal interphalangeal) joint | 99, Unknown

[sympt_jointswell_site(4)]=’1’

1

daily

SYMPTOMS: Indicate if experienced between 00:00 to 24:00 on day of assessment.

sympt_jointswell_hand_num

number

How many small joints of hand affected?

number

1

20

([sympt_jointswell_hand(1)]=’1’ OR [sympt_jointswell_hand(2)]=’1’ OR [sympt_jointswell_hand(3)]=’1’) AND [sympt_jointswell_hand(99)]=’0’

1

daily

SYMPTOMS: Indicate if experienced between 00:00 to 24:00 on day of assessment.

sympt_jointswell_add

checkbox

Indicate other affected joints

1, TMJ | 2, Sternoclavicular (SC) | 3, Acromioclavicular (AC) | 4, Sacroiliac (SI) | 5, Hip | 6, Subtalar | 7, Thoracic spine | 8, Lumbar spine | 88, Other (specify)

[sympt_jointswell_site(88)]=’1’

1

1

daily

SYMPTOMS: Indicate if experienced between 00:00 to 24:00 on day of assessment.

sympt_jointswell_add_oth

text

Specify other joint(s)

[sympt_jointswell_add(88)]=’1’

1

1

daily

SYMPTOMS: Indicate if experienced between 00:00 to 24:00 on day of assessment.

sympt_jointtender

radio

Joint tenderness

1, Yes | 0, No | 99, Unknown

[sympt_dailydata]=’1’

Systemic/General

Defined as pain and discomfort in a joint, often accompanied by sensitivity to touch

Indicate ‘Yes’, if the patient has experienced this at any time from onset of this illness to presentation.

SNOMED

110288007, Tenderness of joint

clinical_features

1

1

daily

SYMPTOMS: Indicate if experienced between 00:00 to 24:00 on day of assessment.

sympt_jointtender_site

checkbox

Indicate affected joints

1, Shoulder | 2, Elbow | 3, Wrist | 4, Small joints of hand | 5, Knee | 6, Ankle |7, Small joints of foot | 88, Other

[sympt_jointtender]=’1’

1

1

daily

SYMPTOMS: Indicate if experienced between 00:00 to 24:00 on day of assessment.

sympt_jointtender_site_shoulder

radio

How many shoulder joints are affected?

1, 1 | 2, 2 | 99, Unknown

[sympt_jointtender_site(1)]=’1’

Systemic/General

1

daily

SYMPTOMS: Indicate if experienced between 00:00 to 24:00 on day of assessment.

sympt_jointtender_site_elbow

radio

How many elbow joints are affected?

1, 1 | 2, 2 | 99, Unknown

[sympt_jointtender_site(2)]=’1’

Systemic/General

1

daily

SYMPTOMS: Indicate if experienced between 00:00 to 24:00 on day of assessment.

sympt_jointtender_site_wrist

radio

How many wrist joints are affected?

1, 1 | 2, 2 | 99, Unknown

[sympt_jointtender_site(3)]=’1’

Systemic/General

1

daily

SYMPTOMS: Indicate if experienced between 00:00 to 24:00 on day of assessment.

sympt_jointtender_site_knee

radio

How many knee joints are affected?

1, 1 | 2, 2 | 99, Unknown

[sympt_jointtender_site(5)]=’1’

Systemic/General

1

daily

SYMPTOMS: Indicate if experienced between 00:00 to 24:00 on day of assessment.

sympt_jointtender_site_ankle

radio

How many ankle joints are affected?

1, 1 | 2, 2 | 99, Unknown

[sympt_jointtender_site(6)]=’1’

Systemic/General

1

daily

SYMPTOMS: Indicate if experienced between 00:00 to 24:00 on day of assessment.

sympt_jointtender_site_foot

number

How many small joints of the foot are affected?

number

1

14

[sympt_jointtender_site(7)]=’1’

Systemic/General

1

daily

SYMPTOMS: Indicate if experienced between 00:00 to 24:00 on day of assessment.

sympt_jointtender_hand

checkbox

Small joints of hand

1, MCP (metacarpophalangeal) joint | 2, PIP (proximal interphalangeal) joint | 3, DIP (distal interphalangeal) joint | 99, Unknown

[sympt_jointtender_site(4)]=’1’

1

daily

SYMPTOMS: Indicate if experienced between 00:00 to 24:00 on day of assessment.

sympt_jointtender_hand_num

number

How many small joints of hand affected?

number

1

20

([sympt_jointtender_hand(1)]=’1’ OR [sympt_jointtender_hand(2)]=’1’ OR [sympt_jointtender_hand(3)]=’1’) AND [sympt_jointtender_hand(99)]=’0’

1

daily

SYMPTOMS: Indicate if experienced between 00:00 to 24:00 on day of assessment.

sympt_jointtender_add

checkbox

Indicate other affected joints

1, TMJ | 2, Sternoclavicular (SC) | 3, Acromioclavicular (AC) | 4, Sacroiliac (SI) | 5, Hip | 6, Subtalar | 7, Thoracic spine | 8, Lumbar spine | 88, Other (specify)

[sympt_jointtender_site(88)]=’1’

1

1

daily

SYMPTOMS: Indicate if experienced between 00:00 to 24:00 on day of assessment.

sympt_jointtender_add_oth

text

Specify other joint(s)

[sympt_jointtender_add(88)]=’1’

1

1

daily

SYMPTOMS: Indicate if experienced between 00:00 to 24:00 on day of assessment.

sympt_stissueswell

radio

Small tissue swelling

1, Yes | 0, No | 99, Unknown

[sympt_dailydata]=’1’

Systemic/General

Defined as painful swelling of the interphalangeal tissue, leading to tension and pain when flexing the fingers

Indicate ‘Yes’, if the patient has experienced this at any time from onset of this illness to presentation.

SNOMED

298349001, Soft tissue swelling

1

daily

SYMPTOMS: Indicate if experienced between 00:00 to 24:00 on day of assessment.

sympt_arthralgia

radio

Joint pain (arthralgia)

1, Yes | 0, No | 99, Unknown

[sympt_dailydata]=’1’ and [initial_assessment_arm_1][demog_calcage_days]>=365

Systemic/General

This refers to a sensation of marked discomfort or pain localised to one or more joints, including small and big joints.

Indicate ‘Yes’, if the patient experienced this between 00:00 to 24:00 on day of assessment.

SNOMED

SNOMED

C3805780, Arthralgia

clinical_features

1

1

1

1

1

1

daily

SYMPTOMS: Indicate if experienced between 00:00 to 24:00 on day of assessment.

sympt_arthralgia_scal

number

Artralgia intensity (Numeric Pain Rating Scale)

number

1

10

[sympt_arthralgia]=’1’

1

daily

SYMPTOMS: Indicate if experienced between 00:00 to 24:00 on day of assessment.

sympt_neurpain

radio

Neuropathic pain

1, Yes | 0, No | 99, Unknown

[sympt_dailydata]=’1’ and [initial_assessment_arm_1][demog_calcage_days]>=365

1

daily

SYMPTOMS: Indicate if experienced between 00:00 to 24:00 on day of assessment.

sympt_neurpain_scal

number

DN4 neuropathic pain scale

number

[sympt_neurpain]=’1’

1

daily

SYMPTOMS: Indicate if experienced between 00:00 to 24:00 on day of assessment.

sympt_dn4

descriptive

DN4 — Douleur Neuropathique 4 Questions (Neuropathic Pain Screening)

[sympt_neurpain]=’1’

1

daily

SYMPTOMS: Indicate if experienced between 00:00 to 24:00 on day of assessment.

sympt_dn4_pain

radio

Does the patient have pain at time of assessment?

1, Yes | 0, No | 99, Unknown

[sympt_neurpain]=’1’

1

daily

SYMPTOMS: Indicate if experienced between 00:00 to 24:00 on day of assessment.

sympt_dn4_q1

descriptive

QUESTION 1 — Does the pain have one or more of the following characteristics?

[sympt_dn4_pain]=’1’

1

daily

SYMPTOMS: Indicate if experienced between 00:00 to 24:00 on day of assessment.

sympt_dn4_q1_burning

radio

  1. Burning

1, Yes | 0, No

[sympt_dn4_pain]=’1’

1

daily

SYMPTOMS: Indicate if experienced between 00:00 to 24:00 on day of assessment.

sympt_dn4_q1_cold

radio

  1. Painful cold

1, Yes | 0, No

[sympt_dn4_pain]=’1’

1

daily

SYMPTOMS: Indicate if experienced between 00:00 to 24:00 on day of assessment.

sympt_dn4_q1_shock

radio

  1. Electric shocks

1, Yes | 0, No

[sympt_dn4_pain]=’1’

1

daily

SYMPTOMS: Indicate if experienced between 00:00 to 24:00 on day of assessment.

sympt_dn4_q2

descriptive

QUESTION 2 — Is the pain associated with one or more of the following symptoms in the same area?

[sympt_dn4_pain]=’1’

1

daily

SYMPTOMS: Indicate if experienced between 00:00 to 24:00 on day of assessment.

sympt_dn4_q2_tingling

radio

  1. Tingling

1, Yes | 0, No

[sympt_dn4_pain]=’1’

1

daily

SYMPTOMS: Indicate if experienced between 00:00 to 24:00 on day of assessment.

sympt_dn4_q2_pins

radio

  1. Pins and needles

1, Yes | 0, No

[sympt_dn4_pain]=’1’

1

daily

SYMPTOMS: Indicate if experienced between 00:00 to 24:00 on day of assessment.

sympt_dn4_q2_numb

radio

  1. Numbness

1, Yes | 0, No

[sympt_dn4_pain]=’1’

1

daily

SYMPTOMS: Indicate if experienced between 00:00 to 24:00 on day of assessment.

sympt_dn4_q2_itch

radio

  1. Itching

1, Yes | 0, No

[sympt_dn4_pain]=’1’

1

daily

SYMPTOMS: Indicate if experienced between 00:00 to 24:00 on day of assessment.

sympt_dn4_q3

descriptive

QUESTION 3 — Is the pain located in an area where the physical examination reveals one or more of the following? (clinician examination)

[sympt_dn4_pain]=’1’

1

daily

SYMPTOMS: Indicate if experienced between 00:00 to 24:00 on day of assessment.

sympt_dn4_q3_touch

radio

  1. Hypoesthesia to touch

1, Yes | 0, No

[sympt_dn4_pain]=’1’

1

daily

SYMPTOMS: Indicate if experienced between 00:00 to 24:00 on day of assessment.

sympt_dn4_q3_pin

radio

  1. Hypoesthesia to pinprick

1, Yes | 0, No

[sympt_dn4_pain]=’1’

1

daily

SYMPTOMS: Indicate if experienced between 00:00 to 24:00 on day of assessment.

sympt_dn4_q4

descriptive

QUESTION 4 — Is the pain provoked or increased by one or more of the following? (clinician examination)

[sympt_dn4_pain]=’1’

1

daily

SYMPTOMS: Indicate if experienced between 00:00 to 24:00 on day of assessment.

sympt_dn4_q4_brush

radio

  1. Brushing

1, Yes | 0, No

[sympt_dn4_pain]=’1’

1

daily

SYMPTOMS: Indicate if experienced between 00:00 to 24:00 on day of assessment.

sympt_dn4_score

calc

DN4 Total Score (0–10)

if([sympt_dn4_pain]=’1’,if([sympt_dn4_q1_burning]=’1’,1,0)+if([sympt_dn4_q1_cold]=’1’,1,0)+if([sympt_dn4_q1_shock]=’1’,1,0)+if([sympt_dn4_q2_tingling]=’1’,1,0)+if([sympt_dn4_q2_pins]=’1’,1,0)+if([sympt_dn4_q2_numb]=’1’,1,0)+if([sympt_dn4_q2_itch]=’1’,1,0)+if([sympt_dn4_q3_touch]=’1’,1,0)+if([sympt_dn4_q3_pin]=’1’,1,0)+if([sympt_dn4_q4_brush]=’1’,1,0),’’)

[sympt_dn4_pain]=’1’

1

daily

SYMPTOMS: Indicate if experienced between 00:00 to 24:00 on day of assessment.

sympt_dn4_result

text

DN4 Result

[sympt_dn4_pain]=’1’

1

daily

SYMPTOMS: Indicate if experienced between 00:00 to 24:00 on day of assessment.

sympt_dn4_notes

notes

Clinical notes (optional)

[sympt_dn4_pain]=’1’

1

daily

SYMPTOMS: Indicate if experienced between 00:00 to 24:00 on day of assessment.

sympt_cramps

radio

Muscle cramps

1, Yes | 0, No | 99, Unknown

[sympt_dailydata]=’1’

sudden, involuntary, painful contractions of one or more muscles that are temporary and usually resolve spontaneously after seconds to minutes.

1

daily

SYMPTOMS: Indicate if experienced between 00:00 to 24:00 on day of assessment.

sympt_skinrash

radio

Skin rash

1, Yes | 0, No | 99, Unknown

[sympt_dailydata]=’1’

Systemic/General

This refers to any change in the skin which affects its appearance or texture. A rash may be localized to one part of the body or affect all the skin. Rashes may cause the skin to change colour, itch, become warm, bumpy, dry, cracked, or blistered, swell and may be painful.

Indicate ‘Yes’, if the patient experienced this between 00:00 to 24:00 on day of assessment.

SNOMED

SNOMED

C4227880, Skin Rash

clinical_features

1

1

1

1

daily

SYMPTOMS: Indicate if experienced between 00:00 to 24:00 on day of assessment.

sympt_paresthesia

radio

Skin paresthesia

1, Yes | 0, No | 99, Unknown

[sympt_dailydata]=’1’ and [initial_assessment_arm_1][demog_calcage_days]>=365

Systemic/General

This refers to percieved cutaneous sensations (e.g., cold, warmth, tingling, pressure, etc.) that are experienced spontaneously in the absence of stimulation.

Indicate ‘Yes’, if the patient experienced this between 00:00 to 24:00 on day of assessment.

1

1

daily

SYMPTOMS: Indicate if experienced between 00:00 to 24:00 on day of assessment.

sympt_skinchange

radio

Changes in skin texture

1, Yes | 0, No | 99, Unknown

[sympt_dailydata]=’1’

Systemic/General

This refers to alterations in the surface appearance and feel of the skin, such as roughness, unevenness, or the presence of bumps.

Indicate ‘Yes’, if the patient experienced this between 00:00 to 24:00 on day of assessment.

1

daily

SYMPTOMS: Indicate if experienced between 00:00 to 24:00 on day of assessment.

sympt_skinpallor

radio

Skin pallor

1, Yes | 0, No | 99, Unknown

[sympt_dailydata]=’1’

Systemic/General

This refers to unnatural pale appearance of the skin.

Indicate ‘Yes’, if the patient experienced this between 00:00 to 24:00 on day of assessment.

1

daily

SYMPTOMS: Indicate if experienced between 00:00 to 24:00 on day of assessment.

sympt_pruritus

radio

Itch (pruritus)

1, Yes | 0, No | 99, Unknown

[sympt_dailydata]=’1’ and [initial_assessment_arm_1][demog_calcage_days]>=183

Systemic/General

Defined as an unpleasant or intense itching sensation that produces the urge to rub or scratch the skin to obtain relief.

Indicate ‘Yes’, if the patient experienced this between 00:00 to 24:00 on day of assessment.

SNOMED

SNOMED

C0033774, Pruritus

clinical_features

1

1

1

1

daily

SYMPTOMS: Indicate if experienced between 00:00 to 24:00 on day of assessment.

sympt_mobilchg

radio

Change in mobility from baseline

1, Yes | 0, No | 99, Unknown

[sympt_dailydata]=’1’

Systemic/General

This refers to the patient’s ability to walk or mobilise.

Indicate ‘Yes’, if the patient experienced this between 00:00 to 24:00 on day of assessment.

SNOMED

SNOMED

C4228638, Unable to walk

clinical_features

1

1

1

1

daily

SYMPTOMS: Indicate if experienced between 00:00 to 24:00 on day of assessment.

sympt_mobile

radio

Mobility status

1, Fully ambulant | 2, Ambulant, but with some assistance | 3, Bedridden

[sympt_dailydata]=’1’ and [initial_assessment_arm_1][demog_calcage_days]>=1825

Systemic/General

This refers to the patient’s ability to walk or mobilise.

Select the most appropriate option(s) represents patient’s mobility status.

SNOMED

SNOMED

C0231435, Mobile | CL573260, Walks with assistance | C0425251, Bed-ridden

clinical_features

1

1

1

1

daily

SYMPTOMS: Indicate if experienced between 00:00 to 24:00 on day of assessment.

sympt_sleepmore

radio

Sleeping more than usual / lethargic / sluggish / listlessness

1, Yes | 0, No | 99, Unknown

[sympt_dailydata]=’1’

Systemic/General

This refers to excessive sleepiness during the daytime / marked by drowsiness and an unusual lack of energy and mental alertness / infant having little energy, is drowsy, or sleeps more than usual

Indicate ‘Yes’, if the patient experienced this between 00:00 to 24:00 on day of assessment.

clinical_features

1

1

daily

SYMPTOMS: Indicate if experienced between 00:00 to 24:00 on day of assessment.

sympt_polydipsia

radio

Increased thirst (polydipsia)

1, Yes | 0, No | 99, Unknown

[sympt_dailydata]=’1’ and [initial_assessment_arm_1][demog_calcage_days]>=365

Systemic/General

This refers to excessive thirst

Indicate ‘Yes’, if the patient experienced this between 00:00 to 24:00 on day of assessment.

clinical_features

1

daily

SYMPTOMS: Indicate if experienced between 00:00 to 24:00 on day of assessment.

sympt_irregmenstruation

radio

Changes in menstruation / Irregular menstruation

1, Yes | 0, No | 99, Unknown

[sympt_dailydata]=’1’ and [initial_assessment_arm_1][demog_sex]=’2’ and [initial_assessment_arm_1][demog_calcage_days]>=2920

Systemic/General

This refers to any deviations from the normal process; e.g. delayed, difficult, profuse, scanty, unusual bleeding, etc.

Indicate ‘Yes’, if the patient experienced this between 00:00 to 24:00 on day of assessment.

clinical_features

1

daily

SYMPTOMS: Indicate if experienced between 00:00 to 24:00 on day of assessment.

sympt_backpain

radio

Back Pain

1, Yes | 0, No | 99, Unknown

[sympt_dailydata]=’1’

Systemic/General

daily

SYMPTOMS: Indicate if experienced between 00:00 to 24:00 on day of assessment.

sympt_neckpain

radio

Neck Pain

1, Yes | 0, No | 99, Unknown

[sympt_dailydata]=’1’

Systemic/General

1

daily

SYMPTOMS: Indicate if experienced between 00:00 to 24:00 on day of assessment.

sympt_resp

descriptive

Respiratory symptoms

[sympt_dailydata]=’1’

Respiratory

This refers to signs and symptoms relating to the respiratory system.

Indicate ‘Yes’, if the patient experienced this between 00:00 to 24:00 on day of assessment.

1

1

1

1

1

1

daily

SYMPTOMS: Indicate if experienced between 00:00 to 24:00 on day of assessment.

sympt_cough

radio

Cough

1, Yes | 0, No | 99, Unknown

[sympt_dailydata]=’1’

Respiratory

This refers to the presence of a cough and its characteristics. A productive cough refers to a cough accompanied by expectorated secretions (phlegm or mucus), while a non-productive cough refers to one which is not accompanied by expectorated secretions. Haemoptysis refers to the presence of blood or blood-streaked sputum from the respiratory tract.

Indicate ‘Yes’, if the patient experienced this between 00:00 to 24:00 on day of assessment.

SNOMED

SNOMED

C0010200, Coughing

clinical_features

1

1

1

1

1

1

daily

SYMPTOMS: Indicate if experienced between 00:00 to 24:00 on day of assessment.

sympt_cough_type

radio

Cough type

1, Non Productive | 2, Productive |3, Haemoptysis |99, Unknown

[sympt_cough] = ‘1’

Respiratory

This refers to the type of cough. A productive cough refers to a cough accompanied by expectorated secretions (phlegm or mucus)

Indicate ‘Yes’, if the patient experienced this between 00:00 to 24:00 on day of assessment.

SNOMED

SNOMED

C0451597 Productive Cough

clinical_features

1

1

1

1

1

1

daily

SYMPTOMS: Indicate if experienced between 00:00 to 24:00 on day of assessment.

sympt_sorethroat

radio

Sore throat

1, Yes | 0, No | 99, Unknown

[sympt_dailydata]=’1’ and [initial_assessment_arm_1][demog_calcage_days]>=365

Respiratory

Defined as an unpleasant sensation characterized by physical discomfort (such as pricking, throbbing, or aching) and perceived to originate in the throat.

Indicate ‘Yes’, if the patient experienced this between 00:00 to 24:00 on day of assessment.

SNOMED

SNOMED

C3854544, Sore throat

clinical_features

1

1

1

1

1

1

daily

SYMPTOMS: Indicate if experienced between 00:00 to 24:00 on day of assessment.

sympt_rhinorrhoe

radio

Runny nose (rhinorrhoea)

1, Yes | 0, No | 99, Unknown

[sympt_dailydata]=’1’

Respiratory

Defined as increased mucosal discharge of the nose.

Indicate ‘Yes’, if the patient experienced this between 00:00 to 24:00 on day of assessment.

SNOMED

SNOMED

C1260880, Rhinorrhea

clinical_features

1

1

1

1

daily

SYMPTOMS: Indicate if experienced between 00:00 to 24:00 on day of assessment.

sympt_wheezing

radio

Wheezing

1, Yes | 0, No | 99, Unknown

[sympt_dailydata]=’1’

Respiratory

Defined as a high-pitched breath sound resulting from a narrowing or obstruction of the small airway.

Indicate ‘Yes’, if the patient experienced this between 00:00 to 24:00 on day of assessment.

SNOMED

SNOMED

C0043144, Wheezing

clinical_features

1

1

daily

SYMPTOMS: Indicate if experienced between 00:00 to 24:00 on day of assessment.

sympt_shortbreat

radio

Shortness of breath

1, Yes | 0, No | 99, Unknown

[sympt_dailydata]=’1’ and [initial_assessment_arm_1][demog_calcage_days]>=365

Respiratory

Defined as the uncomfortable sensation of difficult or laboured breathing that is out of proportion to the patient’s level of physical activity.

Indicate ‘Yes’, if the patient experienced this between 00:00 to 24:00 on day of assessment.

SNOMED

SNOMED

C4230442, Dyspnea

clinical_features

1

1

1

1

1

1

daily

SYMPTOMS: Indicate if experienced between 00:00 to 24:00 on day of assessment.

sympt_nasalcongestion

radio

Nasal congestion

1, Yes | 0, No | 99, Unknown

[sympt_dailydata]=’1’

Respiratory

Defined as reduced ability to pass air through the nasal cavity often leading to mouth breathing.

Indicate ‘Yes’, if the patient experienced this between 00:00 to 24:00 on day of assessment.

clinical_features

1

1

daily

SYMPTOMS: Indicate if experienced between 00:00 to 24:00 on day of assessment.

sympt_chestpain

radio

Chest pain

1, Yes | 0, No | 99, Unknown

[sympt_dailydata]=’1’ and [initial_assessment_arm_1][demog_calcage_days]>=365

Respiratory

Defined as the unpleasant, uncomfortable or painful sensation characterised by physical discomfort localised to the chest.

Indicate ‘Yes’, if the patient experienced this between 00:00 to 24:00 on day of assessment.

SNOMED

SNOMED

C3807341, Chest pain

clinical_features

1

1

1

1

1

daily

SYMPTOMS: Indicate if experienced between 00:00 to 24:00 on day of assessment.

sympt_sneez

radio

Sneezing

1, Yes | 0, No | 99, Unknown

[sympt_dailydata]=’1’

Respiratory

This refers to a sudden violent, spasmodic, audible expiration of breath through the nose and mouth.

Indicate ‘Yes’, if the patient has experienced this at any time from onset of this illness to presentation.

SNOMED

76067001

1

daily

SYMPTOMS: Indicate if experienced between 00:00 to 24:00 on day of assessment.

sympt_hiccups

radio

Hiccups

1, Yes | 0, No | 99, Unknown

[sympt_dailydata]=’1’

Respiratory

daily

SYMPTOMS: Indicate if experienced between 00:00 to 24:00 on day of assessment.

sympt_cvs

descriptive

Cardiovascular symptoms

[sympt_dailydata]=’1’

Cardiovascular

This refers to signs and symptoms relating to the cardiovascular system.

Indicate ‘Yes’, if the patient experienced this between 00:00 to 24:00 on day of assessment.

clinical_features

1

1

1

daily

SYMPTOMS: Indicate if experienced between 00:00 to 24:00 on day of assessment.

sympt_palpitations

radio

Palpitations

1, Yes | 0, No | 99, Unknown

[sympt_dailydata]=’1’

Cardiovascular

Refers to the unpleasant awareness of one’s own heartbeat.

Indicate ‘Yes’, if the patient experienced this between 00:00 to 24:00 on day of assessment.

SNOMED

80313002, Palpitations (finding)

clinical_features

1

1

1

daily

SYMPTOMS: Indicate if experienced between 00:00 to 24:00 on day of assessment.

sympt_git

descriptive

Gastrointestinal symptoms

[sympt_dailydata]=’1’

Gastrointestinal

This refers to signs and symptoms relating to the gastrointestinal system.

Indicate ‘Yes’, if the patient experienced this between 00:00 to 24:00 on day of assessment.

1

1

1

1

1

1

daily

SYMPTOMS: Indicate if experienced between 00:00 to 24:00 on day of assessment.

sympt_abdpain

radio

Abdominal pain

1, Yes | 0, No | 99, Unknown

[sympt_dailydata]=’1’ and [initial_assessment_arm_1][demog_calcage_days]>=365

Gastrointestinal

Defined as an unpleasant sensation of discomfort, distress or agony in the abdominal region.

Indicate ‘Yes’, if the patient experienced this between 00:00 to 24:00 on day of assessment.

SNOMED

SNOMED

C3553274, Abdominal pain

clinical_features

1

1

1

1

1

1

1

1

daily

SYMPTOMS: Indicate if experienced between 00:00 to 24:00 on day of assessment.

sympt_diarrhoea

radio

Diarrhoea

1, Yes | 0, No | 99, Unknown

[sympt_dailydata]=’1’

Gastrointestinal

Defined as three or more loose or liquid bowel movement per day (or more frequent passage than is normal for the individual).

Indicate ‘Yes’, if the patient experienced this between 00:00 to 24:00 on day of assessment.

SNOMED

SNOMED

C3554472, Diarrhea

clinical_features

1

1

1

1

1

1

daily

SYMPTOMS: Indicate if experienced between 00:00 to 24:00 on day of assessment.

sympt_consti

radio

Constipation

1, Yes | 0, No | 99, Unknown

[sympt_dailydata]=’1’

Gastrointestinal

This refers to irregular and infrequent or difficult evacuation of the bowels.

Indicate ‘Yes’, if the patient experienced this between 00:00 to 24:00 on day of assessment.

SNOMED

SNOMED

C3551741, Constipation

clinical_features

1

1

daily

SYMPTOMS: Indicate if experienced between 00:00 to 24:00 on day of assessment.

sympt_vomit

radio

Vomiting

1, Yes | 0, No | 99, Unknown

[sympt_dailydata]=’1’

Gastrointestinal

Defined as the expulsion of the stomach or small intestines through the mouth.

Indicate ‘Yes’, if the patient experienced this between 00:00 to 24:00 on day of assessment.

SNOMED

SNOMED

C4230730, Vomiting

clinical_features

1

1

1

1

1

1

daily

SYMPTOMS: Indicate if experienced between 00:00 to 24:00 on day of assessment.

sympt_vomit2d

radio

Persistent vomiting? (>=2/day)

1, Yes | 0, No | 99, Unknown

[sympt_vomit]=’1’

Gastrointestinal

Persistent vomiting is defined here as vomiting two times or more per day.

Indicate ‘Yes’, if the patient experienced this between 00:00 to 24:00 on day of assessment.

SNOMED

SNOMED

C0152165, Persistent vomiting

clinical_features

1

1

1

1

1

1

daily

SYMPTOMS: Indicate if experienced between 00:00 to 24:00 on day of assessment.

sympt_vomitbld

radio

Vomiting blood (haematemesis)

1, Yes | 0, No | 99, Unknown

[sympt_vomit]=’1’

Gastrointestinal

This refers to vomiting of blood.

Indicate ‘Yes’, if the patient experienced this between 00:00 to 24:00 on day of assessment.

1

daily

SYMPTOMS: Indicate if experienced between 00:00 to 24:00 on day of assessment.

sympt_nausea

radio

Nausea

1, Yes | 0, No | 99, Unknown

[sympt_dailydata]=’1’ and [initial_assessment_arm_1][demog_calcage_days]>=1095

Gastrointestinal

Defined as the the unpleasant painless subjective feeling that one will imminently vomit.

Indicate ‘Yes’, if the patient experienced this between 00:00 to 24:00 on day of assessment.

SNOMED

SNOMED

C3554470, Nausea

clinical_features

1

1

1

1

1

1

daily

SYMPTOMS: Indicate if experienced between 00:00 to 24:00 on day of assessment.

sympt_anorexia

radio

Anorexia

1, Yes | 0, No | 99, Unknown

[sympt_dailydata]=’1’

Gastrointestinal

Defined as lack or loss of appetite.

Indicate ‘Yes’, if the patient experienced this between 00:00 to 24:00 on day of assessment.

SNOMED

SNOMED

C3554473, Anorexia

clinical_features

1

1

1

1

daily

SYMPTOMS: Indicate if experienced between 00:00 to 24:00 on day of assessment.

sympt_exsal

radio

Excessive salivation

1, Yes | 0, No | 99, Unknown

[sympt_dailydata]=’1’ and [initial_assessment_arm_1][demog_calcage_days]>=1460

Gastrointestinal

Excessive salivation or sialorrhea is a symptom best assessed by the patient.

Indicate ‘Yes’, if the patient experienced this between 00:00 to 24:00 on day of assessment.

SNOMED

SNOMED

C0037036, Sialorrhea

clinical_features

1

1

daily

SYMPTOMS: Indicate if experienced between 00:00 to 24:00 on day of assessment.

sympt_diffswallow

radio

Difficulty swallowing (dysphagia)

1, Yes | 0, No | 99, Unknown

[sympt_dailydata]=’1’

Gastrointestinal

Defined as difficulty swallowing food, liquids, or saliva.

Indicate ‘Yes’, if the patient experienced this between 00:00 to 24:00 on day of assessment.

SNOMED

SNOMED

C0011168, Deglutition Disorders

clinical_features

1

1

daily

SYMPTOMS: Indicate if experienced between 00:00 to 24:00 on day of assessment.

sympt_faecalincont

radio

Faecal incontinence

1, Yes | 0, No | 99, Unknown

[sympt_dailydata]=’1’ and [initial_assessment_arm_1][demog_calcage_days]>=1825

Gastrointestinal

Defined as failure of voluntary control of the anal sphincters, with involuntary passage of feces and flatus.

Indicate ‘Yes’, if the patient experienced this between 00:00 to 24:00 on day of assessment.

clinical_features

1

daily

SYMPTOMS: Indicate if experienced between 00:00 to 24:00 on day of assessment.

sympt_renalgut

descriptive

Renal / Genitourinary symptoms

[sympt_dailydata]=’1’

Genitourinary

This refers to signs and symptoms relating to the renal / genitourinary system.

Indicate ‘Yes’, if the patient experienced this between 00:00 to 24:00 on day of assessment.

1

1

daily

SYMPTOMS: Indicate if experienced between 00:00 to 24:00 on day of assessment.

sympt_urine

radio

Urinary retention

1, Yes | 0, No | 99, Unknown

[sympt_dailydata]=’1’

Genitourinary

Defined as the accumulation of urine within the bladder because of the inability to urinate.

Indicate ‘Yes’, if the patient experienced this between 00:00 to 24:00 on day of assessment.

SNOMED

SNOMED

C0080274, Urinary retention

clinical_features

1

1

daily

SYMPTOMS: Indicate if experienced between 00:00 to 24:00 on day of assessment.

sympt_urineincont

radio

Urinary incontinence

1, Yes | 0, No | 99, Unknown

[sympt_dailydata]=’1’ and [initial_assessment_arm_1][demog_calcage_days]>=1825

Genitourinary

This refers to loss of bladder control, or being unable to control urination.

Indicate ‘Yes’, if the patient experienced this between 00:00 to 24:00 on day of assessment.

clinical_features

1

daily

SYMPTOMS: Indicate if experienced between 00:00 to 24:00 on day of assessment.

sympt_polyuria

radio

Increased urination (polyuria)

1, Yes | 0, No | 99, Unknown

[sympt_dailydata]=’1’

Genitourinary

This refers to excessive or frequent urination.

Indicate ‘Yes’, if the patient experienced this between 00:00 to 24:00 on day of assessment.

clinical_features

1

daily

SYMPTOMS: Indicate if experienced between 00:00 to 24:00 on day of assessment.

sympt_dysuria

radio

Pain during urination (dysuria)

1, Yes | 0, No | 99, Unknown

[sympt_dailydata]=’1’ and [initial_assessment_arm_1][demog_calcage_days]>=365

Genitourinary

This refers to painful or difficult urination.

Indicate ‘Yes’, if the patient experienced this between 00:00 to 24:00 on day of assessment.

clinical_features

1

daily

SYMPTOMS: Indicate if experienced between 00:00 to 24:00 on day of assessment.

sympt_dyspareunia

radio

Painful intercourse (dyspareunia)

1, Yes | 0, No | 99, Unknown

[sympt_dailydata]=’1’ and [initial_assessment_arm_1][demog_calcage_days]>=5475

Genitourinary

Defined as recurrent or persistent genital pain associated with sexual intercourse.

Indicate ‘Yes’, if the patient experienced this between 00:00 to 24:00 on day of assessment.

SNOMED

SNOMED

C1384606, Dyspareunia

clinical_features

1

1

daily

SYMPTOMS: Indicate if experienced between 00:00 to 24:00 on day of assessment.

sympt_heme

descriptive

Haematological symptoms

[sympt_dailydata]=’1’

Haematology

This refers to signs and symptoms relating to the haematological system.

Indicate ‘Yes’, if the patient experienced this between 00:00 to 24:00 on day of assessment.

1

1

1

1

1

1

1

daily

SYMPTOMS: Indicate if experienced between 00:00 to 24:00 on day of assessment.

sympt_haemorrhag

radio

Bleeding (haemorrhage)

1, Yes | 0, No | 99, Unknown

[sympt_dailydata]=’1’

Haematology

Defined as the presence of blood in a location in which it is not physiologically normal or loss of blood from the circulation, either internally or externally. This can include epistaxis (blood from nose), gingival bleeding (blood from gums/gingiva), blood from any part of the gastrointestinal tract (gastrointestinal bleeding) or genitourinary tracts (vagina or urethra) including hematuria.

Indicate ‘Yes’, if the patient experienced this between 00:00 to 24:00 on day of assessment.

SNOMED

SNOMED

C3163616, Blood loss

clinical_features

1

1

1

1

1

1

1

1

1

daily

SYMPTOMS: Indicate if experienced between 00:00 to 24:00 on day of assessment.

sympt_haemorrhag_sev

radio

Severe bleeding (requires intervention)

1, Yes | 0, No | 99, Unknown

[sympt_haemorrhag]=’1’

Haematology

Defined as the severe bleeding / hemorrhage requiring medical intervention for hemostasis and/or hemodynamic support.

Indicate ‘Yes’, if the patient experienced this between 00:00 to 24:00 on day of assessment.

clinical_features

1

1

1

1

1

1

1

1

daily

SYMPTOMS: Indicate if experienced between 00:00 to 24:00 on day of assessment.

sympt_haemorrhag_site

multi_list

Specify bleeding site(s)

conditions_Site

[sympt_haemorrhag] = ‘1’

Haematology

This refers to the location of bleeding/haemorrhage site(s). Petechiae refer to small reddish or purplish spots in skin or mucous membrane as a result of localised haemorrhage. Nose bleeding refers to haemorrhage localized in the nose. Gum bleeding refers to haemorrhage affecting the gingiva. Gastrointestinal (GI) bleeding refers to haemorrhage in any segment of the gastrointestinal tract from oesophagus to rectum. Urinary tract bleeding refers to haemorrhage originating from any part of the urinary system. Vaginal bleeding refers to haemorrhage originating from vagina, unrelated to normal menstruation.

Select the most appropriate option(s) corresponding to the location of bleeding/haemorrhage site(s).

SNOMED

SNOMED

C0574741, Bleeding skin | C3808808, Epistaxis | C0017565, Gingival haemorrrhage | C0017181, Gastrointestinal haemorrhage |C3805433, haematuria | C0566961, Fresh bleeding from vagina

clinical_features

1

1

1

1

1

1

1

1

1

daily

SYMPTOMS: Indicate if experienced between 00:00 to 24:00 on day of assessment.

sympt_cns

descriptive

Neurological symptoms

[sympt_dailydata]=’1’

Nervous system

This refers to signs and symptoms relating to the neurological system.

Indicate ‘Yes’, if the patient experienced this between 00:00 to 24:00 on day of assessment.

1

1

1

1

1

1

daily

SYMPTOMS: Indicate if experienced between 00:00 to 24:00 on day of assessment.

sympt_headache

radio

Headache

1, Yes | 0, No | 99, Unknown

[sympt_dailydata]=’1’ and [initial_assessment_arm_1][demog_calcage_days]>=365

Nervous system

Defined as the experience of pain in various parts of the head, not confined to the area of distribution of any nerve.

Indicate ‘Yes’, if the patient experienced this between 00:00 to 24:00 on day of assessment.

SNOMED

SNOMED

C0018681, Headache

clinical_features

1

1

1

1

1

1

daily

SYMPTOMS: Indicate if experienced between 00:00 to 24:00 on day of assessment.

sympt_photoph

radio

Photophobia

1, Yes | 0, No | 99, Unknown

[sympt_dailydata]=’1’

Nervous system

Refers to increased sensitivity of the eyes to light.

Indicate ‘Yes’, if the patient experienced this between 00:00 to 24:00 on day of assessment.

SNOMED

SNOMED

C3807325, Photophobia

clinical_features

1

1

daily

SYMPTOMS: Indicate if experienced between 00:00 to 24:00 on day of assessment.

sympt_seizconv

radio

Seizures / convulsions

1, Yes | 0, No | 99, Unknown

[sympt_dailydata]=’1’

Nervous system

Defined as an intermittent abnormality of nervous system physiology characterised by a transient occurrence of sudden, violent, irregular movement of the body, caused by involuntary contraction of muscles due to abnormal excessive or synchronous neuronal activity in the brain.

Indicate ‘Yes’, if the patient experienced this between 00:00 to 24:00 on day of assessment.

SNOMED

SNOMED

C2748942, Seizure

clinical_features

1

1

1

1

1

1

1

1

1

daily

SYMPTOMS: Indicate if experienced between 00:00 to 24:00 on day of assessment.

sympt_confusion

radio

Altered consciousness / confusion

1, Yes | 0, No | 99, Unknown

[sympt_dailydata]=’1’

Nervous system

Defined as a level of awareness or arousal other than the patient’s normal baseline.

Indicate ‘Yes’, if the patient experienced this between 00:00 to 24:00 on day of assessment.

SNOMED

SNOMED

C0150450, Altered level of consciousness

clinical_features

1

1

1

1

1

1

1

1

1

daily

SYMPTOMS: Indicate if experienced between 00:00 to 24:00 on day of assessment.

sympt_paralysis

radio

Paralysis

1, Yes | 0, No | 99, Unknown

[sympt_dailydata]=’1’

Nervous system

This refers to inability to fully move or control movement

Indicate ‘Yes’, if the patient experienced this between 00:00 to 24:00 on day of assessment.

clinical_features

1

1

1

daily

SYMPTOMS: Indicate if experienced between 00:00 to 24:00 on day of assessment.

sympt_irritable

radio

Irritability

1, Yes | 0, No | 99, Unknown

[sympt_dailydata]=’1’

Nervous system

Refers to an abnormal or excessive excitability with easily triggered anger, annoyance, or impatience.

Indicate ‘Yes’, if the patient experienced this between 00:00 to 24:00 on day of assessment.

clinical_features

1

1

1

daily

SYMPTOMS: Indicate if experienced between 00:00 to 24:00 on day of assessment.

sympt_tremor

radio

Tremor

1, Yes | 0, No | 99, Unknown

[sympt_dailydata]=’1’

Nervous system

Refers to an unintentional, oscillating to-and-fro muscle movement about a joint axis.

Indicate ‘Yes’, if the patient experienced this between 00:00 to 24:00 on day of assessment.

SNOMED

SNOMED

C0040822, Tremor

clinical_features

1

1

1

daily

SYMPTOMS: Indicate if experienced between 00:00 to 24:00 on day of assessment.

sympt_diffwalk

radio

Difficulty in walking

1, Yes | 0, No | 99, Unknown

[sympt_dailydata]=’1’ and [initial_assessment_arm_1][demog_calcage_days]>=292

Nervous system

This refers to any persistent problem with walking.

Indicate ‘Yes’, if the patient has experienced this at any time from onset of this illness to presentation.

clinical_features

1

1

1

daily

SYMPTOMS: Indicate if experienced between 00:00 to 24:00 on day of assessment.

sympt_neurologic

radio

Other neurological abnormality

1, Yes | 0, No | 99, Unknown

[sympt_dailydata]=’1’

Nervous system

This refers the presence of an alternative neurological abnormality not listed above.

Indicate ‘Yes’, if the patient experienced this between 00:00 to 24:00 on day of assessment.

clinical_features

1

1

1

daily

SYMPTOMS: Indicate if experienced between 00:00 to 24:00 on day of assessment.

sympt_neurologic_spec

text

Specify other neurological abnormality

[sympt_neurologic] = ‘1’

Nervous system

This refers the presence of another neurological abnormality not listed above.

If ‘Other’, specify neurological abnormality.

clinical_features

1

1

daily

SYMPTOMS: Indicate if experienced between 00:00 to 24:00 on day of assessment.

sympt_eye

descriptive

Opthalmological symptoms

[sympt_dailydata]=’1’

Nervous system

This refers to signs and symptoms relating to the eye.

Indicate ‘Yes’, if the patient experienced this between 00:00 to 24:00 on day of assessment.

1

1

1

1

1

daily

SYMPTOMS: Indicate if experienced between 00:00 to 24:00 on day of assessment.

sympt_itchyeye

radio

Itching of eye(s)

1, Yes | 0, No | 99, Unknown

[sympt_dailydata]=’1’ and [initial_assessment_arm_1][demog_calcage_days]>=365

Ocular

Defined as itching of one or both eyes.

Indicate ‘Yes’, if the patient experienced this between 00:00 to 24:00 on day of assessment.

SNOMED

SNOMED

clinical_features

1

1

1

daily

SYMPTOMS: Indicate if experienced between 00:00 to 24:00 on day of assessment.

sympt_redeye

radio

Red / Pink eye(s)

1, Yes | 0, No | 99, Unknown

[sympt_dailydata]=’1’

Ocular

Defined as inflammation or infection of the conjunctiva, characterized by redness in one or both eyes.

Indicate ‘Yes’, if the patient experienced this between 00:00 to 24:00 on day of assessment.

SNOMED

SNOMED

clinical_features

1

1

1

1

daily

SYMPTOMS: Indicate if experienced between 00:00 to 24:00 on day of assessment.

sympt_paineyes

radio

Pain in eye(s)

1, Yes | 0, No | 99, Unknown

[sympt_dailydata]=’1’

Ocular

Defined as discomfort or aching localized within or around the eye area.

Indicate ‘Yes’, if the patient experienced this between 00:00 to 24:00 on day of assessment.

SNOMED

SNOMED

clinical_features

1

1

1

daily

SYMPTOMS: Indicate if experienced between 00:00 to 24:00 on day of assessment.

sympt_eyelidedema

radio

Oedema of eyelid(s)

1, Yes | 0, No | 99, Unknown

[sympt_dailydata]=’1’

Ocular

Defined as swelling due to fluid accumulation in the tissues of the eyelid.

Indicate ‘Yes’, if the patient experienced this between 00:00 to 24:00 on day of assessment.

SNOMED

SNOMED

clinical_features

1

daily

SYMPTOMS: Indicate if experienced between 00:00 to 24:00 on day of assessment.

sympt_eyedischarg

radio

Discharge from eye(s)

1, Yes | 0, No | 99, Unknown

[sympt_dailydata]=’1’

Ocular

Defined as the release of fluids ranging from clear to pus-like from the eye, often indicative of infection or irritation.

Indicate ‘Yes’, if the patient experienced this between 00:00 to 24:00 on day of assessment.

SNOMED

SNOMED

clinical_features

1

daily

SYMPTOMS: Indicate if experienced between 00:00 to 24:00 on day of assessment.

sympt_hazyvision

radio

Hazy / Blurred vision

1, Yes | 0, No | 99, Unknown

[sympt_dailydata]=’1’

Ocular

Defined as a loss of visual acuity, resulting in unclear or distorted sight.

Indicate ‘Yes’, if the patient experienced this between 00:00 to 24:00 on day of assessment.

SNOMED

SNOMED

clinical_features

1

1

daily

SYMPTOMS: Indicate if experienced between 00:00 to 24:00 on day of assessment.

sympt_eyelightsensi

radio

Sensitivity of eye to light

1, Yes | 0, No | 99, Unknown

[sympt_dailydata]=’1’

Ocular

Defined as an abnormal intolerance to light, causing discomfort or pain in the eyes when exposed to bright light.

Indicate ‘Yes’, if the patient experienced this between 00:00 to 24:00 on day of assessment.

SNOMED

SNOMED

clinical_features

1

1

daily

SYMPTOMS: Indicate if experienced between 00:00 to 24:00 on day of assessment.

sympt_visdist

radio

Visual disturbance

1, Yes | 0, No | 99, Unknown

[sympt_dailydata]=’1’

Ocular

Refers to an interference to normal eyesight without necessarily affecting visual acuity.

Indicate ‘Yes’, if the patient experienced this between 00:00 to 24:00 on day of assessment.

63102001, Visual distrubance

clinical_features

1

1

1

daily

SYMPTOMS: Indicate if experienced between 00:00 to 24:00 on day of assessment.

sympt_ocularoth

radio

Other opthalmological symptoms

1, Yes | 0, No | 99, Unknown

[sympt_dailydata]=’1’

Ocular

This refers to other signs and symptoms relating to the eye, not specified above.

Indicate ‘Yes’, if the patient experienced this between 00:00 to 24:00 on day of assessment.

1

1

1

1

daily

SYMPTOMS: Indicate if experienced between 00:00 to 24:00 on day of assessment.

sympt_ocularoth_spec

text

Specify other opthalmological symptoms

[sympt_dailydata]=’1’

Ocular

This refers to other signs and symptoms relating to the eye, not specified above.

If ‘Yes’, specify other opthalmological signs and symptoms

1

1

1

1

daily

SYMPTOMS: Indicate if experienced between 00:00 to 24:00 on day of assessment.

sympt_ent

descriptive

Ear/Nose/Throat symptoms

[sympt_dailydata]=’1’

ENT

This refers to signs and symptoms relating to the ear, nose and throat.

Indicate ‘Yes’, if the patient experienced this between 00:00 to 24:00 on day of assessment.

clinical_features

1

1

daily

SYMPTOMS: Indicate if experienced between 00:00 to 24:00 on day of assessment.

sympt_earpain

radio

Ear pain

1, Yes | 0, No | 99, Unknown

[sympt_dailydata]=’1’

ENT

This refers to painful sensation in the ear

Indicate ‘Yes’, if the patient experienced this between 00:00 to 24:00 on day of assessment.

clinical_features

1

1

daily

SYMPTOMS: Indicate if experienced between 00:00 to 24:00 on day of assessment.

sympt_tinnitus

radio

Tinnitus

1, Yes | 0, No | 99, Unknown

[sympt_dailydata]=’1’

ENT

This refers to an abnormal perception of sounds experienced by an individual in the absence of auditory stimulation.

Indicate ‘Yes’, if the patient experienced this between 00:00 to 24:00 on day of assessment.

clinical_features

1

1

daily

SYMPTOMS: Indicate if experienced between 00:00 to 24:00 on day of assessment.

sympt_parot

radio

Parotitis

1, Yes | 0, No | 99, Unknown

[sympt_dailydata]=’1’

ENT

This refers to inflammation of the parotid glands.

Indicate ‘Yes’, if the patient has experienced between 00:00 to 24:00 on day of assessment.

clinical_features

1

daily

SYMPTOMS: Indicate if experienced between 00:00 to 24:00 on day of assessment.

sympt_paed

descriptive

Paediatric-specific symptoms

[sympt_dailydata] = ‘1’ and [initial_assessment_arm_1][demog_calcage_days]<=365

1

1

1

daily

SYMPTOMS: Indicate if experienced between 00:00 to 24:00 on day of assessment.

sympt_contcry

radio

Continuous crying

1, Yes | 0, No | 99, Unknown

[sympt_dailydata] = ‘1’ and [initial_assessment_arm_1][demog_calcage_days]<=365

1

1

1

daily

SYMPTOMS: Indicate if experienced between 00:00 to 24:00 on day of assessment.

sympt_feedingdiff

radio

Feeding difficulty

1, Yes | 0, No | 99, Unknown

[sympt_dailydata] = ‘1’ and [initial_assessment_arm_1][demog_calcage_days]<=365

1

1

1

daily

SYMPTOMS: Indicate if experienced between 00:00 to 24:00 on day of assessment.

sympt_otherdesc

descriptive

Other symptoms

[sympt_dailydata]=’1’

Other

1

1

1

1

daily

SYMPTOMS: Indicate if experienced between 00:00 to 24:00 on day of assessment.

sympt_unlisted

list

Other symptom(s)

1, Yes | 0, No | 99, Unknown

conditions_Symptoms

[sympt_dailydata]=’1’

Other

This refers the presence of an alternative sign(s) or symptom(s) not listed above.

Indicate ‘Yes’, if the patient has experienced another sign or symptom not listed above between 00:00 to 24:00 on day of assessment.

clinical_features

1

1

1

1

daily

SIGNS: Record the clinical findings observed between 00:00 and 24:00 on the day of assessment

sign_dailydata

radio

Enter clinical signs data for this date?

1, Yes | 0, No

This refers to signs and symptoms recorded o this date.

Indicate ‘Yes’, if you want to record signs and symptoms data for this day of assessment.

SNOMED

SNOMED

C0037088, signs

1

1

1

1

1

1

1

1

daily

SIGNS: Record the clinical findings observed between 00:00 and 24:00 on the day of assessment

sign_sys

descriptive

Systemic / general signs

[sign_dailydata]=’1’

Systemic/General

This refers to systemic / general / non-specific signs and symptoms

Indicate ‘Yes’, if the patient experienced this between 00:00 to 24:00 on day of assessment.

1

1

1

1

1

1

1

1

daily

SIGNS: Record the clinical findings observed between 00:00 and 24:00 on the day of assessment

sign_hypotherm

radio

Hypothermia

1, Yes | 0, No | 99, Unknown

[sign_dailydata]=’1’

Systemic/General

This refers to abnormally reduced body temperature due to failed thermoregulation.

Indicate ‘Yes’, if the patient experienced this between 00:00 to 24:00 on day of assessment.

1

daily

SIGNS: Record the clinical findings observed between 00:00 and 24:00 on the day of assessment

sign_coldperiph

radio

Cold / clammy peripheries

1, Yes | 0, No | 99, Unknown

[sign_dailydata]=’1’

Systemic/General

This refers to skin that feels cool and moist to the touch, often associated with circulatory failure and symptoms like restlessness and hypotension.

Indicate ‘Yes’, if the patient experienced this between 00:00 to 24:00 on day of assessment.

SNOMED

C2106366, cold and clammy extremities

1

1

1

1

1

daily

SIGNS: Record the clinical findings observed between 00:00 and 24:00 on the day of assessment

sign_dehyrdation

radio

Dehydration

1, Yes | 0, No | 99, Unknown

[sign_dailydata]=’1’

Systemic/General

This refers to excessive loss of water from the body.

Indicate ‘Yes’, if the patient experienced this between 00:00 to 24:00 on day of assessment.

daily

SIGNS: Record the clinical findings observed between 00:00 and 24:00 on the day of assessment

sign_dehyrdation_type

radio

Dehydration Status

1, Mild | 2, Moderate| 3, Severe

[sign_dehyrdation]=’1’

Systemic/General

This refers to excessive loss of water from the body.

Indicate ‘Yes’, if the patient has experienced this at any time from onset of this illness to presentation.

SNOMED

34095006, Dehydration (disorder)

C0011175, Dehydration

clinical_features

daily

SIGNS: Record the clinical findings observed between 00:00 and 24:00 on the day of assessment

sign_oedema

radio

Oedema

1, Yes | 0, No | 99, Unknown

[sign_dailydata]=’1’

Systemic/General

This refers to accumulation of an excessive amount of fluid in cells or intercellular tissues.

Indicate ‘Yes’, if the patient experienced this between 00:00 to 24:00 on day of assessment.

1

1

1

1

1

1

1

daily

SIGNS: Record the clinical findings observed between 00:00 and 24:00 on the day of assessment

sign_oedema_site

checkbox

Oedema site(s)

1, Feet | 2, Ankle | 3, Legs (below knee) | 4, Legs (above knees) | 5, Scrotum/Labia | 6, Sacrum | 7, Abdomen | 8, Neck | 9, Face | 99, Unknown | 88, Other

[sign_oedema] = ‘1’

Systemic/General

This refers to the location of the odema.

If ‘Yes’, specify the location of the oedema. Select all that apply.

1

1

1

1

1

daily

SIGNS: Record the clinical findings observed between 00:00 and 24:00 on the day of assessment

sign_oedema_site_oth

text

Specify other oedema site(s)

[sign_oedema_site(88)] = ‘1’

Systemic/General

This refers to the location of the odema.

If ‘Other’, specify the site of oedema

1

1

1

1

daily

SIGNS: Record the clinical findings observed between 00:00 and 24:00 on the day of assessment

sign_lymph

radio

Lymphadenopathy

1, Yes-painful | 2, Yes-not painful | 0, No | 99, Unknown

[sign_dailydata]=’1’

Systemic/General

Defined as a clinical finding of abnormal enlargement of the lymph nodes.

Indicate ‘Yes’, if the patient has experienced between 00:00 to 24:00 on day of assessment.

SNOMED

SNOMED

C4014613, Lymphadenopathy

clinical_features

1

1

1

1

1

1

1

daily

SIGNS: Record the clinical findings observed between 00:00 and 24:00 on the day of assessment

sign_lymph_site

checkbox

Specify lymphadenopathy site(s)

1, Axillary (arm pits) | 2, Cervical (neck)| 3, Inguinal (groin) | 99, Unknown | 88, Other

[sign_lymph]=’1’ or [sign_lymph]=’2’

Systemic/General

This refers to the location in which lymphadenopathy was identified.

Select the most appropriate option(s) corresponding to the location of lymphadenopathy.

SNOMED

SNOMED

clinical_features

1

1

1

1

1

1

daily

SIGNS: Record the clinical findings observed between 00:00 and 24:00 on the day of assessment

sign_lymph_site_oth

text

Specify other lymphadenopathy site(s)

[sign_lymph_site(88)]=’1’

Systemic/General

This refers to the location in which lymphadenopathy was identified.

If ‘Other’, write the location in which lymphadenopathy was identified.

clinical_features

1

1

1

1

1

1

daily

SIGNS: Record the clinical findings observed between 00:00 and 24:00 on the day of assessment

sign_lowurine

radio

Reduced urine output

1, Yes | 0, No | 99, Unknown

[sign_dailydata]=’1’

Genitourinary

This refers to a finding indicating that the urine production is less than 500 milliliters during a 24 hour period.

Indicate ‘Yes’, if the patient experienced this between 00:00 to 24:00 on day of assessment.

1

1

1

daily

SIGNS: Record the clinical findings observed between 00:00 and 24:00 on the day of assessment

sign_bruise

radio

Bruising

1, Yes | 0, No | 99, Unknown

[sign_dailydata]=’1’

Systemic/General

This refers to spontaneous extravasation of blood into the subcutaneous space, also referred to as spontaneous ecchymoses.

Indicate ‘Yes’, if the patient experienced this between 00:00 to 24:00 on day of assessment.

1

1

1

daily

SIGNS: Record the clinical findings observed between 00:00 and 24:00 on the day of assessment

sign_alopecia

radio

Alopecia

1, Yes | 0, No | 99, Unknown

[sign_dailydata]=’1’

Systemic/General

This refers to absence of hair (nonscarring hair loss) from areas where it is normally present.

Indicate ‘Yes’, if the patient experienced this between 00:00 to 24:00 on day of assessment.

1

daily

SIGNS: Record the clinical findings observed between 00:00 and 24:00 on the day of assessment

sign_dryskin

radio

Dry skin

1, Yes | 0, No | 99, Unknown

[sign_dailydata]=’1’

Systemic/General

This refers to skin characterized by the lack of natural or normal moisture resulting from inadequate hydrolipids in the skin, also called xerosis cutis.

Indicate ‘Yes’, if the patient experienced this between 00:00 to 24:00 on day of assessment.

1

daily

SIGNS: Record the clinical findings observed between 00:00 and 24:00 on the day of assessment

sign_oralulcer

radio

Oral ulcers

1, Yes | 0, No | 99, Unknown

[sign_dailydata]=’1’

Systemic/General

This refers to recurrent episodes of ulceration of the oral mucosa (recurrent oral aphthae), typically presenting as painful, sharply circumscribed fibrin-covered mucosal defects with a h

Indicate ‘Yes’, if the patient experienced this between 00:00 to 24:00 on day of assessment.

1

daily

SIGNS: Record the clinical findings observed between 00:00 and 24:00 on the day of assessment

sign_presinj

radio

Pressure injury to skin

1, Yes | 0, No | 99, Unknown

[sign_dailydata]=’1’

1

daily

SIGNS: Record the clinical findings observed between 00:00 and 24:00 on the day of assessment

sign_mastitis

radio

Mastitis

1, Yes | 0, No | 99, Unknown

[sign_dailydata]=’1’

Breast

Defined as a inflammation of the breast, with or without accompanying infection

Indicate ‘Yes’, if the patient experienced this at any time during the date of assessment.

SNOMED

SNOMED

C0149613, Acute mastitis

clinical_features

1

1

daily

SIGNS: Record the clinical findings observed between 00:00 and 24:00 on the day of assessment

sign_bacsi

radio

Bacterial super-infection

1, Yes | 0, No | 99, Unknown

[sign_dailydata]=’1’

Systemic/General

Defined as a physician-diagnosed secondary bacterial infection that occurs during an existing wound, infection or immediately following an earlier infection.

Indicate ‘Yes’, if the patient has experienced between 00:00 to 24:00 on day of assessment.

SNOMED

SNOMED

C0442886, Secondary infections

clinical_features

daily

SIGNS: Record the clinical findings observed between 00:00 and 24:00 on the day of assessment

sign_bacsi_spec

checkbox

Specify bacterial super-infection.

7, Deep tissue abscess | 1, Folliculitis / cellulitis | 2, Pneumonia | 3, Gastroenteritis | 4, CNS | 5, Bacteraemia | 6, Urinary tract | 88, Other

[sign_bacsi]=’1’

Systemic/General

This refers to the type or location of the bacterial super-infection.

Select the most appropriate option(s) represents the type or location of the bacterial super-infection.

SNOMED

SNOMED

C0037278, Skin Infection | C0339952, Secondary bacterial pneumonia | C0558348, Bacterial gastroenteritis | C0752180, Bacterial infection of central nervous system | C1096222, Urinary tract infection bacterial

clinical_features

daily

SIGNS: Record the clinical findings observed between 00:00 and 24:00 on the day of assessment

sign_bacsi_oth

text

Specify other bacterial super-infection

[sign_bacsi_spec(88)]=’1’

Systemic/General

This refers to the other type(s) or location(s) of the bacterial super-infection, not specified above.

If ‘Other’, write the type or location of the bacterial super-infection.

clinical_features

daily

SIGNS: Record the clinical findings observed between 00:00 and 24:00 on the day of assessment

sign_resp

descriptive

Respiratory signs

[sign_dailydata]=’1’

Respiratory

This refers to signs and symptoms relating to the respiratory system.

Indicate ‘Yes’, if the patient experienced this between 00:00 to 24:00 on day of assessment.

1

1

1

1

1

1

1

daily

SIGNS: Record the clinical findings observed between 00:00 and 24:00 on the day of assessment

sign_respdistress

radio

Respiratory distress

1, Yes | 0, No | 99, Unknown

[sign_dailydata]=’1’

Respiratory

This refer to a pathological increase in the effort and frequency of breathing movements.

Indicate ‘Yes’, if the patient experienced this between 00:00 to 24:00 on day of assessment.

1

1

1

1

1

1

daily

SIGNS: Record the clinical findings observed between 00:00 and 24:00 on the day of assessment

sign_chestindrw

radio

Lower chest wall indrawing

1, Yes | 0, No | 99, Unknown

[sign_dailydata]=’1’

Respiratory

Defined as a clinical sign of respiratory distress, distinguished by the abnormal inward movement of the lower chest wall during inspiration. If only the soft tissue between the ribs or above the clavicle goes in when the patient breathes, this is not lower chest wall in-drawing.

Indicate ‘Yes’, if the patient experienced this between 00:00 to 24:00 on day of assessment.

SNOMED

SNOMED

C0231906, Chest wall retraction

clinical_features

1

1

1

1

daily

SIGNS: Record the clinical findings observed between 00:00 and 24:00 on the day of assessment

sign_tachypnoea

radio

Fast breathing (tachypnoea)

1, Yes | 0, No | 99, Unknown

[sign_dailydata]=’1’

Respiratory

Defined as an abnormal increase of rate of breathing.

Indicate ‘Yes’, if the patient experienced this between 00:00 to 24:00 on day of assessment.

1

1

daily

SIGNS: Record the clinical findings observed between 00:00 and 24:00 on the day of assessment

sign_apnoea

radio

Apnoea

1, Yes | 0, No | 99, Unknown

[sign_dailydata]=’1’

Respiratory

Defined as a transient absence in spontaneous respiration.

Indicate ‘Yes’, if the patient experienced this between 00:00 to 24:00 on day of assessment.

clinical_features

1

daily

SIGNS: Record the clinical findings observed between 00:00 and 24:00 on the day of assessment

sign_rhinitis

radio

Rhinitis

1, Yes | 0, No | 99, Unknown

[sign_dailydata]=’1’

Respiratory

Defined as inflammation of the mucous membrane lining the nose, usually associated with nasal discharge.

Indicate ‘Yes’, if the patient experienced this between 00:00 to 24:00 on day of assessment.

1

daily

SIGNS: Record the clinical findings observed between 00:00 and 24:00 on the day of assessment

sign_phary

radio

Pharyngitis

1, Yes | 0, No | 99, Unknown

[sign_dailydata]=’1’

Respiratory

This refers to the presence of inflammation of the throat..

Indicate ‘Yes’, if the patient experienced this between 00:00 to 24:00 on day of assessment.

SNOMED

SNOMED

C0031350, Pharyngitis

clinical_features

1

1

1

1

daily

SIGNS: Record the clinical findings observed between 00:00 and 24:00 on the day of assessment

sign_pharery

radio

Pharyngeal erythema

1, Yes | 0, No | 99, Unknown

[sign_dailydata]=’1’

Respiratory

Indicate ‘Yes’, if the patient has experienced this at any time from onset of this illness to presentation.

clinical_features

daily

SIGNS: Record the clinical findings observed between 00:00 and 24:00 on the day of assessment

sign_pharexu

radio

Pharyngeal exudate

1, Yes | 0, No | 99, Unknown

[sign_dailydata]=’1’

Respiratory

Indicate ‘Yes’, if the patient has experienced this at any time from onset of this illness to presentation.

clinical_features

daily

SIGNS: Record the clinical findings observed between 00:00 and 24:00 on the day of assessment

sign_tonsil

radio

Tonsillitis

1, Yes | 0, No | 99, Unknown

[sign_dailydata]=’1’

Respiratory

This refers to the presence of inflammation of the tonsils.

Indicate ‘Yes’, if the patient experienced this between 00:00 to 24:00 on day of assessment.

SNOMED

SNOMED

C0040425, Tonsillitis

clinical_features

1

1

1

daily

SIGNS: Record the clinical findings observed between 00:00 and 24:00 on the day of assessment

sign_plueeff

radio

Pleural effusion

1, Yes | 0, No | 99, Unknown

[sign_dailydata]=’1’

Respiratory

This refers to presence of fluid in the pleural cavity resulting from excessive transudation or exudation from the pleural surfaces.

Indicate ‘Yes’, if the patient experienced this between 00:00 to 24:00 on day of assessment.

1

1

1

1

1

daily

SIGNS: Record the clinical findings observed between 00:00 and 24:00 on the day of assessment

sign_cvs

descriptive

Cardiovascular signs

[sign_dailydata]=’1’

Cardiovascular

This refers to signs and symptoms relating to the cardiovascular system.

Indicate ‘Yes’, if the patient experienced this between 00:00 to 24:00 on day of assessment.

clinical_features

1

1

1

daily

SIGNS: Record the clinical findings observed between 00:00 and 24:00 on the day of assessment

sign_tachycardia

radio

Rapid heart rate (tachycardia)

1, Yes | 0, No | 99, Unknown

[sign_dailydata]=’1’

Cardiovascular

Refers to an abnormally rapid heart rate (typically > 100bpm for adults), that exceeds the range of the normal resting heart rate for age.

Indicate ‘Yes’, if the patient experienced this between 00:00 to 24:00 on day of assessment.

clinical_features

1

1

daily

SIGNS: Record the clinical findings observed between 00:00 and 24:00 on the day of assessment

sign_arrhythmia

radio

Cardiac arrhythmia

1, Yes | 0, No | 99, Unknown

[sign_dailydata]=’1’

Cardiovascular

Refers to an abnormality in rhythm of heartbeat, including rate, regularity, and/or sequence of activation abnormalities

Indicate ‘Yes’, if the patient experienced this between 00:00 to 24:00 on day of assessment.

clinical_features

1

1

1

daily

SIGNS: Record the clinical findings observed between 00:00 and 24:00 on the day of assessment

sign_cyan

radio

Peripheral cyanosis

1, Yes | 0, No | 99, Unknown

[sign_dailydata]=’1’

Cardiovascular

1

daily

SIGNS: Record the clinical findings observed between 00:00 and 24:00 on the day of assessment

sign_git

descriptive

Gastrointestinal signs

[sign_dailydata]=’1’

Gastrointestinal

This refers to signs and symptoms relating to the gastrointestinal system.

Indicate ‘Yes’, if the patient experienced this between 00:00 to 24:00 on day of assessment.

1

1

1

1

1

1

1

daily

SIGNS: Record the clinical findings observed between 00:00 and 24:00 on the day of assessment

sign_ascites

radio

Ascites

1, Yes | 0, No | 99, Unknown

[sign_dailydata]=’1’

Gastrointestinal

Defined as an excessive accumulation or retention of free fluid within the peritoneal cavity.

Indicate ‘Yes’, if the patient experienced this between 00:00 to 24:00 on day of assessment.

clinical_features

1

1

1

1

1

daily

SIGNS: Record the clinical findings observed between 00:00 and 24:00 on the day of assessment

sign_hepatomegally

radio

Palpable liver/Hepatomegaly

1, Yes | 0, No | 99, Unknown

[sign_dailydata]=’1’

Gastrointestinal

Defined as an pathological enlargement of the liver

Indicate ‘Yes’, if the patient experienced this between 00:00 to 24:00 on day of assessment.

clinical_features

1

1

1

1

1

1

daily

SIGNS: Record the clinical findings observed between 00:00 and 24:00 on the day of assessment

sign_splenomegaly

radio

Palpable spleen/splenomegaly

1, Yes | 0, No | 99, Unknown

[sign_dailydata]=’1’

Gastrointestinal

Indicate ‘Yes’, if the patient has experienced this at any time from onset of this illness to presentation.

clinical_features

1

1

daily

SIGNS: Record the clinical findings observed between 00:00 and 24:00 on the day of assessment

sign_tenabd

radio

Tender abdomen

1, Yes | 0, No | 99, Unknown

[sign_dailydata]=’1’

Gastrointestinal

Indicate ‘Yes’, if the patient has experienced this at any time from onset of this illness to presentation.

clinical_features

daily

SIGNS: Record the clinical findings observed between 00:00 and 24:00 on the day of assessment

sign_jaund

radio

Jaundice

1, Yes | 0, No | 99, Unknown

[sign_dailydata]=’1’

Gastrointestinal

Defined as a clinical manifestation of hyperbilirubinemia, characterized by the yellowish staining of the skin, mucous membrane and/or sclera.

Indicate ‘Yes’, if the patient experienced this between 00:00 to 24:00 on day of assessment.

SNOMED

SNOMED

C3549846, Jaundice

clinical_features

1

1

1

1

1

1

1

1

daily

SIGNS: Record the clinical findings observed between 00:00 and 24:00 on the day of assessment

sign_melaena

radio

Dark / tarry blood in faeces (melaena)

1, Yes | 0, No | 99, Unknown

[sign_dailydata]=’1’

Gastrointestinal

This refers to abnormally dark tarry feces containing blood, usually from gastrointestinal bleeding.

Indicate ‘Yes’, if the patient experienced this between 00:00 to 24:00 on day of assessment.

1

1

daily

SIGNS: Record the clinical findings observed between 00:00 and 24:00 on the day of assessment

sign_haematochezia

radio

Fresh blood in stools (haematochezia)

1, Yes | 0, No | 99, Unknown

[sign_dailydata]=’1’

Gastrointestinal

This refers to the presence of blood in stool. It is the result of gastrointestinal hemorrhage and it may be easily seen in stool or may be identified microscopically.

Indicate ‘Yes’, if the patient experienced this between 00:00 to 24:00 on day of assessment.

1

daily

SIGNS: Record the clinical findings observed between 00:00 and 24:00 on the day of assessment

sign_rectalbleed

radio

Rectal bleeding

1, Yes | 0, No | 99, Unknown

[sign_dailydata]=’1’

Gastrointestinal

This refers to bleeding originating from the rectal wall and discharged from the anus.

Indicate ‘Yes’, if the patient experienced this between 00:00 to 24:00 on day of assessment.

1

1

daily

SIGNS: Record the clinical findings observed between 00:00 and 24:00 on the day of assessment

sign_feeding

radio

Feeding

1, Able | 0,Unable | 2, NBM order

[sign_dailydata]=’1’

Gastrointestinal

daily

SIGNS: Record the clinical findings observed between 00:00 and 24:00 on the day of assessment

sign_feeding_route

radio

If able to feed, specify route:

1, Oral | 2, Feeding Tube | 3, Breastfeeding

[sign_feeding]=’1’

Gastrointestinal

daily

SIGNS: Record the clinical findings observed between 00:00 and 24:00 on the day of assessment

sign_heme

descriptive

Haematological signs

[sign_dailydata]=’1’

Haematology

This refers to signs and symptoms relating to the haematological system.

Indicate ‘Yes’, if the patient experienced this between 00:00 to 24:00 on day of assessment.

1

1

daily

SIGNS: Record the clinical findings observed between 00:00 and 24:00 on the day of assessment

sign_anaemia

radio

Anaemia

1, Yes | 0, No | 99, Unknown

[sign_dailydata]=’1’

Haematology

This refers to a reduction in the number of red blood cells, the amount of hemoglobin, and/or the volume of packed red blood cells. Common manifestations include pallor, fatigue, dizziness, shortness of breath, and tachycardia.

Indicate ‘Yes’, if the patient experienced this between 00:00 to 24:00 on day of assessment.

1

1

daily

SIGNS: Record the clinical findings observed between 00:00 and 24:00 on the day of assessment

sign_cns

descriptive

Neurological signs

[sign_dailydata]=’1’

Nervous system

This refers to signs and symptoms relating to the neurological system.

Indicate ‘Yes’, if the patient experienced this between 00:00 to 24:00 on day of assessment.

1

1

1

1

1

1

1

daily

SIGNS: Record the clinical findings observed between 00:00 and 24:00 on the day of assessment

sign_neckstiff

radio

Neck stiffness

1, Yes | 0, No | 99, Unknown

[sign_dailydata]=’1’

Nervous system

Defined as a sensation of tightness in the neck when attempting to move it, especially after a period of inactivity. Neck stiffness often involves soreness and difficulty moving the neck, especially when trying to turn the head to the side.

Indicate ‘Yes’, if the patient experienced this between 00:00 to 24:00 on day of assessment.

SNOMED

SNOMED

C0151315, Neck Stiffness

clinical_features

1

1

1

1

daily

SIGNS: Record the clinical findings observed between 00:00 and 24:00 on the day of assessment

sign_retroorbit

radio

Retro-orbital pain

1, Yes | 0, No | 99, Unknown

[sign_dailydata]=’1’

Nervous system

Defined as the experience of pain in the retro-orbital region (behind the eyes).

Indicate ‘Yes’, if the patient experienced this between 00:00 to 24:00 on day of assessment.

MedDRA

MedDRA

C0743724, Retro-orbital pain

clinical_features

1

1

daily

SIGNS: Record the clinical findings observed between 00:00 and 24:00 on the day of assessment

sign_hemiplegia

radio

Hemiplegia

1, Yes | 0, No | 99, Unknown

[sign_dailydata]=’1’

Nervous system

This refers to severe or complete loss of motor function on one side of the body; often caused by brain diseases that are localized to the cerebral hemisphere opposite to the side of weakness; less frequently, brain stem lesions; cervical spinal cord diseases, peripheral nervous system diseases, and other conditions may manifest as hemiplegia.

Indicate ‘Yes’, if the patient experienced this between 00:00 to 24:00 on day of assessment.

clinical_features

1

1

daily

SIGNS: Record the clinical findings observed between 00:00 and 24:00 on the day of assessment

sign_cogimpair

radio

Cognitive impairment

1, Yes | 0, No | 99, Unknown

[sign_dailydata]=’1’

Nervous system

This refers to diminished or impaired mental and/or intellectual function.

Indicate ‘Yes’, if the patient experienced this between 00:00 to 24:00 on day of assessment.

clinical_features

1

1

daily

SIGNS: Record the clinical findings observed between 00:00 and 24:00 on the day of assessment

sign_neurodist

radio

Psychological disturbance

1, Yes | 0, No | 99, Unknown

[sign_dailydata]=’1’

Nervous system

This refers to the presence of signs or symptoms that affect an individual’s thoughts, emotions, behaviours or mental well-being. The presence of psychological disturbances should be identified through a Mental Status Examination (MSE) or equivalent tool.

Indicate ‘Yes’, if the patient experienced this between 00:00 to 24:00 on day of assessment.

SNOMED

SNOMED

C0233395, Psychological sign or symptom

clinical_features

1

1

1

daily

SIGNS: Record the clinical findings observed between 00:00 and 24:00 on the day of assessment

sign_speechdist

radio

Speech disturbance

1, Yes | 0, No | 99, Unknown

[sign_dailydata]=’1’

Nervous system

This refers to difficulties with speech and communication that may result from pathologies in the brain.

Indicate ‘Yes’, if the patient experienced this between 00:00 to 24:00 on day of assessment.

1

1

1

daily

SIGNS: Record the clinical findings observed between 00:00 and 24:00 on the day of assessment

sign_agitation

radio

Agitation

1, Yes | 0, No | 99, Unknown

[sign_dailydata]=’1’

Nervous system

This refers to a state of excessive motor activity that is associated with mental distress or a feeling of substantial unease or inner tension. Distinguished from restlessness by the increased level of emotional distress and negative intensity of the experience. Agitation has a significant level of physical activity that is typically threatening to the self or others.

C0085631, Agitation

clinical_features

1

1

1

1

1

daily

SIGNS: Record the clinical findings observed between 00:00 and 24:00 on the day of assessment

sign_cerebesig

radio

Cerebellar signs

1, Yes | 0, No | 99, Unknown

[sign_dailydata]=’1’

Nervous system

Refers to the presence of a constellation of neurological signs typically indicate cerebellar dysfunction. Signs include dysdiadochokinesia, dysmetria, ataxia, nystagmus, intention tremor, slurred or scanning speech, hypotonia.

Indicate ‘Yes’, if the patient experienced this between 00:00 to 24:00 on day of assessment.

C3807868, Cerebellar signs

clinical_features

1

1

daily

SIGNS: Record the clinical findings observed between 00:00 and 24:00 on the day of assessment

sign_neurologic

radio

Other neurological abnormality

1, Yes | 0, No | 99, Unknown

[sign_dailydata]=’1’

Nervous system

This refers the presence of an alternative neurological abnormality not listed above.

Indicate ‘Yes’, if the patient experienced this between 00:00 to 24:00 on day of assessment.

clinical_features

1

1

1

daily

SIGNS: Record the clinical findings observed between 00:00 and 24:00 on the day of assessment

sign_neurologic_spec

text

Specify other neurological abnormality

[sign_neurologic] = ‘1’

Nervous system

This refers the presence of another neurological abnormality not listed above.

If ‘Other’, specify neurological abnormality.

clinical_features

1

1

daily

SIGNS: Record the clinical findings observed between 00:00 and 24:00 on the day of assessment

sign_eye

descriptive

Opthalmological signs

[sign_dailydata]=’1’

Nervous system

This refers to signs and symptoms relating to the eye.

Indicate ‘Yes’, if the patient experienced this between 00:00 to 24:00 on day of assessment.

1

1

1

1

1

1

daily

SIGNS: Record the clinical findings observed between 00:00 and 24:00 on the day of assessment

sign_conjunhemor

radio

Subconjunctival haemorrhage

1, Yes | 0, No | 99, Unknown

[sign_dailydata]=’1’

Ocular

Defined as the accumulation of blood underneath the conjunctiva, presenting as a bright red or dark patch in the eye.

Indicate ‘Yes’, if the patient experienced this between 00:00 to 24:00 on day of assessment.

SNOMED

SNOMED

clinical_features

1

1

daily

SIGNS: Record the clinical findings observed between 00:00 and 24:00 on the day of assessment

sign_conjunctiv

radio

Conjunctivitis

1, Yes | 0, No | 99, Unknown

[sign_dailydata]=’1’

Ocular

Defined as inflammation of the conjunctiva

Indicate ‘Yes’, if the patient experienced this between 00:00 to 24:00 on day of assessment.

SNOMED

SNOMED

C4011653, Conjunctivitis

clinical_features

1

1

1

1

1

daily

SIGNS: Record the clinical findings observed between 00:00 and 24:00 on the day of assessment

sign_keratitis

radio

Keratitis

1, Yes | 0, No | 99, Unknown

[sign_dailydata]=’1’

Ocular

This refers to inflammation of the cornea of the eye.

Indicate ‘Yes’, if the patient experienced this between 00:00 to 24:00 on day of assessment.

clinical_features

1

daily

SIGNS: Record the clinical findings observed between 00:00 and 24:00 on the day of assessment

sign_newvision

radio

Newly reduced visual acuity

1, Yes | 0, No | 99, Unknown

[sign_dailydata]=’1’

Ocular

Defined as decreased clarity or sharpness of vision.

Indicate ‘Yes’, if the patient experienced this between 00:00 to 24:00 on day of assessment.

SNOMED

SNOMED

clinical_features

1

1

1

daily

SIGNS: Record the clinical findings observed between 00:00 and 24:00 on the day of assessment

sign_sunkeyes

radio

Sunken eyes

1, Yes | 0, No | 99, Unknown

[sign_dailydata]=’1’

Ocular

Indicate ‘Yes’, if the patient has experienced this at any time from onset of this illness to presentation.

clinical_features

daily

SIGNS: Record the clinical findings observed between 00:00 and 24:00 on the day of assessment

sign_ocularoth

radio

Other opthalmological signs

1, Yes | 0, No | 99, Unknown

[sign_dailydata]=’1’

Ocular

This refers to other signs and symptoms relating to the eye, not specified above.

Indicate ‘Yes’, if the patient experienced this between 00:00 to 24:00 on day of assessment.

1

1

daily

SIGNS: Record the clinical findings observed between 00:00 and 24:00 on the day of assessment

sign_ocularoth_spec

text

Specify other opthalmological signs

[sign_dailydata]=’1’

Ocular

This refers to other signs and symptoms relating to the eye, not specified above.

If ‘Yes’, specify other opthalmological signs and symptoms

1

1

daily

SIGNS: Record the clinical findings observed between 00:00 and 24:00 on the day of assessment

sign_paed

descriptive

Paediatric-specific signs

[sign_dailydata] = ‘1’ and [initial_assessment_arm_1][demog_calcage_days]<=1825

Paediatric

1

1

1

daily

SIGNS: Record the clinical findings observed between 00:00 and 24:00 on the day of assessment

sign_nasalflar

radio

Nasal flaring

1, Yes | 0, No | 99, Unknown

[sign_dailydata] = ‘1’ and [initial_assessment_arm_1][demog_calcage_days]<=1825

Paediatric

1

1

daily

SIGNS: Record the clinical findings observed between 00:00 and 24:00 on the day of assessment

sign_grunt

radio

Grunting

1, Yes | 0, No | 99, Unknown

[sign_dailydata] = ‘1’ and [initial_assessment_arm_1][demog_calcage_days]<=1825

Paediatric

1

1

daily

SIGNS: Record the clinical findings observed between 00:00 and 24:00 on the day of assessment

sign_ftt

radio

Failure to thrive

1, Yes | 0, No | 99, Unknown

[sign_dailydata] = ‘1’ and [initial_assessment_arm_1][demog_calcage_days]<=28

Paediatric

1

daily

SIGNS: Record the clinical findings observed between 00:00 and 24:00 on the day of assessment

sign_hypotonia

radio

Decreased tone / hypotonia

1, Yes | 0, No | 99, Unknown

[sign_dailydata] = ‘1’ and [initial_assessment_arm_1][demog_calcage_days]<=28

Paediatric

1

daily

SIGNS: Record the clinical findings observed between 00:00 and 24:00 on the day of assessment

sign_bulgefont

radio

Bulging fontanelle

1, Yes | 0, No | 99, Unknown

[sign_dailydata] = ‘1’ and [initial_assessment_arm_1][demog_calcage_days]<=28

Paediatric

1

daily

SIGNS: Record the clinical findings observed between 00:00 and 24:00 on the day of assessment

sign_otherdesc

descriptive

Other signs

[sign_dailydata]=’1’

Other

1

1

1

1

1

daily

SIGNS: Record the clinical findings observed between 00:00 and 24:00 on the day of assessment

sign_unlisted

list

Other sign(s)

1, Yes | 0, No | 99, Unknown

conditions_Symptoms

[sign_dailydata]=’1’

Other

This refers the presence of an alternative sign(s) or symptom(s) not listed above.

Indicate ‘Yes’, if the patient has experienced another sign or symptom not listed above between 00:00 to 24:00 on day of assessment.

clinical_features

1

1

1

1

1

1

daily

SKIN & MUCOSA ASSESSMENT: Record the information furthest from normal between 00:00 to 24:00 on day of assessment.

lesion_dailydata

radio

Enter Skin and Mucosa Assessment data for this date?

1, Yes | 0, No

The following questions pertain to clinical inspection of skin lesions. Data recorded in this section should detail the conditions present on the date of assessment. This section should be completed for date of admission and any subsequent day as per the local protocol.

Indicate ‘Yes’, to enter information pertaining to clinical inspection of skin lesions on the day of assessment.

clinical_features

1

1

daily

SKIN & MUCOSA ASSESSMENT: Record the information furthest from normal between 00:00 to 24:00 on day of assessment.

lesion_dist

radio

Rash distribution

1, Generalised | 2, Localised around the genitals | 3, Centrifugal-more on the extremities | 4, Centripetal-more on the trunk | 88, Other distribution | 99, Unknown distribution

[lesion_dailydata]=’1’

Skin

This refers to the pattern of distribution of the skin rash. Generalised rash refers to a widespread rash covering the entire surface of the skin. Centrifugal rash is concentrated on the distal extremities, with fewer lesions on the trunk. Centripetal rash is concentrated on the trunk, with fewer lesions on the extremities. Localised around the genitals refers to a rash concentrated around the skin on the genitals.

Select the most appropriate pattern of distribution of the skin rash on the day of assessment.

1

1

daily

SKIN & MUCOSA ASSESSMENT: Record the information furthest from normal between 00:00 to 24:00 on day of assessment.

lesion_distoth

text

Specify other rash distribution

[lesion_dist]=’88’

Skin

This refers to the pattern of distribution of the skin rash.

If ‘Other’, write the pattern of distribution of the skin rash on the day of assessment.

1

1

daily

SKIN & MUCOSA ASSESSMENT: Record the information furthest from normal between 00:00 to 24:00 on day of assessment.

lesion_morph

radio

Rash morphology

1, Mostly discrete lesions | 2, Semi-confluent lesions | 3, Confluent lesions | 4, Mixed morphology | 99, Unknown

[lesion_dailydata]=’1’

Skin

This refers to the predominant morphology of the skin rash. Discrete lesions refer to separate, distinct lesions that are not joined to one another. Confluent lesions refer to lesions that are joining or running together.

Select the most appropriate morphology of the skin rash on the day of assessment.

1

1

daily

SKIN & MUCOSA ASSESSMENT: Record the information furthest from normal between 00:00 to 24:00 on day of assessment.

lesion_morphsize

radio

Rash size (skin) - widest diameter of any lesion

1, Less than 0.5cm | 2, 0.5-0.99cm | 3, 1-1.99cm | 4, 2+ cm

[lesion_dailydata]=’1’

Skin

This refers to the size of the skin rash, recorded as the widest diameter of any lesion in centimetres (cm).

Indicate the widest diameter of any skin lesion measured in centimetres (cm) on the day of assessment.

1

1

daily

SKIN & MUCOSA ASSESSMENT: Record the information furthest from normal between 00:00 to 24:00 on day of assessment.

lesion_skinles

radio

Current skin lesion status

1, There are active skin lesions | 2, There are skin lesions and none of them are active (lesions in the process of healing & resolving, including scabbed lesions) | 3, All skin lesions have completely resolved (all scabs have fallen off with intact skin) | 4, No skin lesions have developed to date

[lesion_dailydata]=’1’

Skin

This refers to the status of the skin lesions. Active skin lesions refer to macules (flat lesions), papules (raised lesions), vesicles (raised and filled with clear fluid) or pustules (raised and filed with pus, an opaque fluid) which can develop a depression in the centre (umbilication) or ulcerate. Skin lesions which are not active refer to those which have begun to crust (dry) over, in the process of healing & resolving, to form scabs (consisting of dried serum, blood, or pus). Skin lesions which have completely resolved refer to all scabs having fallen off, leaving intact underlying skin.

Indicate the most appropriate dermatological status of the skin lesions on the day of assessment.

1

1

daily

SKIN & MUCOSA ASSESSMENT: Record the information furthest from normal between 00:00 to 24:00 on day of assessment.

lesion_res

radio

Is there residual evidence of resolved skin lesions (scar/discolouration)?

1, Yes | 0, No | 99, Unknown

[lesion_skinles]=’2’ or [lesion_skinles]=’3’ or [lesion_skinles]=’4’

This refers to the presence of sequalae secondary to resolved or resolving skin lesions i.e. lesions that are no longer active (including scabbed lesions and lesions where all scabs have fallen off with intact skin). This can include scars or discoloration.

Indicate ‘Yes’, if there is residual evidence of resolved skin lesions on the day of assessment.

1

1

daily

SKIN & MUCOSA ASSESSMENT: Record the information furthest from normal between 00:00 to 24:00 on day of assessment.

lesion_mucos

radio

Current mucosal lesion status

1, There are mucosal lesions | 2, There is a history of mucosal lesions but none at present (all have resolved and mucosa is healed) | 3, No mucosal lesions have developed to date

[lesion_dailydata]=’1’

This refers to the presence of mucosal membrane involvement. It includes the lining of the digestive tract, respiratory tract and genitourinary tract.

Select the single most appropriate option that represents the extent of mucosal involvement between 00:00 to 24:00 on day of assessment.

1

1

daily

SKIN & MUCOSA ASSESSMENT: Record the information furthest from normal between 00:00 to 24:00 on day of assessment.

lesion_orophar

radio

If there are mucosal lesions: Persistent symptoms or signs of mucosal oropharyngeal lesions

1, Yes | 0, No | 99, Unknown

[lesion_mucos]=’1’

This refers to the presence of mucosal membrane involvement in the oropharyngeal cavity, as evidenced by active mucosal lesions, erythema, inflammatory changes. Symptoms may include sore throat, painful ulcerations, painful or difficult swallowing.

Indicate ‘Yes’, if the patient had symptoms of mucosal oropharyngeal lesions between 00:00 to 24:00 on day of assessment.

1

1

daily

SKIN & MUCOSA ASSESSMENT: Record the information furthest from normal between 00:00 to 24:00 on day of assessment.

lesion_oropharles

radio

Oro-pharyngeal ulcerated lesion (active)

1, Yes | 0, No | 99, Unknown

[lesion_orophar]=’1’

This refers to active ulcerated mucosal lesions in the area between the soft palate and the upper portion of the epiglottis.

Indicate ‘Yes’, if there are active lesions involving this area between 00:00 to 24:00 on day of assessment.

1

1

daily

SKIN & MUCOSA ASSESSMENT: Record the information furthest from normal between 00:00 to 24:00 on day of assessment.

lesion_head

radio

Are there any lesions on the head, face or neck?

1, Yes | 0, No | 99, Unknown

[lesion_skinles]=’1’

This refers to presence of skin lesions involving the head, face or neck.

Indicate ‘Yes’, if there are active lesions involving this area between 00:00 to 24:00 on day of assessment.

1

1

daily

SKIN & MUCOSA ASSESSMENT: Record the information furthest from normal between 00:00 to 24:00 on day of assessment.

lesion_head_type

checkbox

Type of head, face or neck lesions

1, Vesicle | 2, Pustule | 3, Ulcerated lesions | 4, Necrotising lesions | 5, Fungating lesions | 6, Haemorrhagic lesions | 88, Other

[lesion_head]=’1’

This refers to the type of skin lesions involving the head, face or neck. Vesicle refers to raised lesion and filled with clear fluid. Pustule refers to raised lesion and filed with pus, an opaque fluid. Ulcerated lesion refers to a lesion with break in the skin. Necrotising lesion refers to a lesion with necrotic (dead) tissue. Fungating lesion refers to a lesion from underlying tissues which is breaking through the skin’s surface.

Select the single most appropriate option that represents the type of lesions involving this area, between 00:00 to 24:00 on day of assessment.

1

1

daily

SKIN & MUCOSA ASSESSMENT: Record the information furthest from normal between 00:00 to 24:00 on day of assessment.

lesion_head_type_oth

text

Specify other type of head, face or neck lesions

[lesion_head_type(88)]=’1’

This refers to the type of skin lesions involving the head, face or neck.

If ‘Other’. Write the type of lesions involving this area, between 00:00 to 24:00 on day of assessment.

1

1

daily

SKIN & MUCOSA ASSESSMENT: Record the information furthest from normal between 00:00 to 24:00 on day of assessment.

lesion_head_num

text

Number of head, face or neck lesions

[lesion_head]=’1’

This refers to the number of skin lesions involving the head, face or neck.

Write the number of lesions involving this area, between 00:00 to 24:00 on day of assessment.

1

1

daily

SKIN & MUCOSA ASSESSMENT: Record the information furthest from normal between 00:00 to 24:00 on day of assessment.

lesion_ocular

radio

Are there any ocular lesions within the orbit?

1, Yes | 0, No | 99, Unknown

[lesion_skinles]=’1’

Ocular

This refers to the presence of ocular lesions.

Indicate ‘Yes’, if there are active lesions involving this area between 00:00 to 24:00 on day of assessment.

1

1

daily

SKIN & MUCOSA ASSESSMENT: Record the information furthest from normal between 00:00 to 24:00 on day of assessment.

lesion_ocular_type

checkbox

Type of ocular lesions

1, Vesicle | 2, Pustule | 3, Ulcerated lesions | 4, Necrotising lesions | 5, Fungating lesions | 6, Haemorrhagic lesions | 88, Other

[lesion_ocular]=’1’

Ocular

This refers to the type of ocular lesion. Vesicle refers to raised lesion and filled with clear fluid. Pustule refers to raised lesion and filed with pus, an opaque fluid. Ulcerated lesion refers to a lesion with break in the skin. Necrotising lesion refers to a lesion with necrotic (dead) tissue. Fungating lesion refers to a lesion from underlying tissues which is breaking through the skin’s surface.

Select the single most appropriate option that represents the type of lesions involving this area, between 00:00 to 24:00 on day of assessment.

1

1

daily

SKIN & MUCOSA ASSESSMENT: Record the information furthest from normal between 00:00 to 24:00 on day of assessment.

lesion_ocular_type_oth

text

Specify other type of ocular lesions

[lesion_ocular_type(88)]=’1’

Ocular

This refers to the type of ocular lesion.

If ‘Other’. Write the type of lesions involving this area, between 00:00 to 24:00 on day of assessment.

1

1

daily

SKIN & MUCOSA ASSESSMENT: Record the information furthest from normal between 00:00 to 24:00 on day of assessment.

lesion_ocular_num

text

Number of ocular lesions

[lesion_ocular]=’1’

Ocular

This refers to the number of ocular lesions.

Write the number of lesions involving this area, between 00:00 to 24:00 on day of assessment.

1

1

daily

SKIN & MUCOSA ASSESSMENT: Record the information furthest from normal between 00:00 to 24:00 on day of assessment.

lesion_torso

radio

Are there any lesions on the torso / trunk?

1, Yes | 0, No | 99, Unknown

[lesion_skinles]=’1’

Skin

This refers to presence of skin lesions involving the torso / trunk.

Indicate ‘Yes’, if there are active lesions involving this area between 00:00 to 24:00 on day of assessment.

1

1

daily

SKIN & MUCOSA ASSESSMENT: Record the information furthest from normal between 00:00 to 24:00 on day of assessment.

lesion_torso_type

checkbox

Type of torso / trunk lesions

1, Vesicle | 2, Pustule | 3, Ulcerated lesions | 4, Necrotising lesions | 5, Fungating lesions | 6, Haemorrhagic lesions | 88, Other

[lesion_torso]=’1’

Skin

This refers to the type of skin lesions involving the torso / trunk. Vesicle refers to raised lesion and filled with clear fluid. Pustule refers to raised lesion and filed with pus, an opaque fluid. Ulcerated lesion refers to a lesion with break in the skin. Necrotising lesion refers to a lesion with necrotic (dead) tissue. Fungating lesion refers to a lesion from underlying tissues which is breaking through the skin’s surface.

Select the single most appropriate option that represents the type of lesions involving this area, between 00:00 to 24:00 on day of assessment.

1

1

daily

SKIN & MUCOSA ASSESSMENT: Record the information furthest from normal between 00:00 to 24:00 on day of assessment.

lesion_torso_type_oth

text

Specify other type of torso / trunk lesions

[lesion_torso_type(88)]=’1’

Skin

This refers to the type of skin lesions involving the torso / trunk.

If ‘Other’. Write the type of lesions involving this area, between 00:00 to 24:00 on day of assessment.

1

1

daily

SKIN & MUCOSA ASSESSMENT: Record the information furthest from normal between 00:00 to 24:00 on day of assessment.

lesion_torso_num

text

Number of torso / trunk lesions

[lesion_torso]=’1’

Skin

This refers to the number of skin lesions involving the torso / trunk.

Write the number of lesions involving this area, between 00:00 to 24:00 on day of assessment.

1

1

daily

SKIN & MUCOSA ASSESSMENT: Record the information furthest from normal between 00:00 to 24:00 on day of assessment.

lesion_arms

radio

Are there any lesions on the arms and/or hands?

1, Yes | 0, No | 99, Unknown

[lesion_skinles]=’1’

Skin

This refers to presence of skin lesions involving the arms and/or hands.

Indicate ‘Yes’, if there are active lesions involving this area between 00:00 to 24:00 on day of assessment.

1

1

daily

SKIN & MUCOSA ASSESSMENT: Record the information furthest from normal between 00:00 to 24:00 on day of assessment.

lesion_arms_type

checkbox

Type of arms / hands lesions

1, Vesicle | 2, Pustule | 3, Ulcerated lesions | 4, Necrotising lesions | 5, Fungating lesions | 6, Haemorrhagic lesions | 88, Other

[lesion_arms]=’1’

Skin

This refers to the type of skin lesions involving the arms and/or hands. Vesicle refers to raised lesion and filled with clear fluid. Pustule refers to raised lesion and filed with pus, an opaque fluid. Ulcerated lesion refers to a lesion with break in the skin. Necrotising lesion refers to a lesion with necrotic (dead) tissue. Fungating lesion refers to a lesion from underlying tissues which is breaking through the skin’s surface.

Select the single most appropriate option that represents the type of lesions involving this area, between 00:00 to 24:00 on day of assessment.

1

1

daily

SKIN & MUCOSA ASSESSMENT: Record the information furthest from normal between 00:00 to 24:00 on day of assessment.

lesion_arms_type_oth

text

Specify other type of arms / hands lesions

[lesion_arms_type(88)]=’1’

Skin

This refers to the type of skin lesions involving the arms and/or hands.

If ‘Other’. Write the type of lesions involving this area, between 00:00 to 24:00 on day of assessment.

1

1

daily

SKIN & MUCOSA ASSESSMENT: Record the information furthest from normal between 00:00 to 24:00 on day of assessment.

lesion_arms_num

text

Number of arms / hands lesions

[lesion_arms]=’1’

Skin

This refers to the number of skin lesions involving the arms and/or hands.

Write the number of lesions involving this area, between 00:00 to 24:00 on day of assessment.

1

1

daily

SKIN & MUCOSA ASSESSMENT: Record the information furthest from normal between 00:00 to 24:00 on day of assessment.

lesion_legs

radio

Are there any lesions on the legs and/or feet?

1, Yes | 0, No | 99, Unknown

[lesion_skinles]=’1’

Skin

This refers to presence of skin lesions involving the legs and/or feet.

Indicate ‘Yes’, if there are active lesions involving this area between 00:00 to 24:00 on day of assessment.

1

1

daily

SKIN & MUCOSA ASSESSMENT: Record the information furthest from normal between 00:00 to 24:00 on day of assessment.

lesion_legs_type

checkbox

Type of legs / feet lesions

1, Vesicle | 2, Pustule | 3, Ulcerated lesions | 4, Necrotising lesions | 5, Fungating lesions | 6, Haemorrhagic lesions | 88, Other

[lesion_legs]=’1’

Skin

This refers to the type of skin lesions involving the legs and/or feet. Vesicle refers to raised lesion and filled with clear fluid. Pustule refers to raised lesion and filed with pus, an opaque fluid. Ulcerated lesion refers to a lesion with break in the skin. Necrotising lesion refers to a lesion with necrotic (dead) tissue. Fungating lesion refers to a lesion from underlying tissues which is breaking through the skin’s surface.

Select the single most appropriate option that represents the type of lesions involving this area, between 00:00 to 24:00 on day of assessment.

1

1

daily

SKIN & MUCOSA ASSESSMENT: Record the information furthest from normal between 00:00 to 24:00 on day of assessment.

lesion_legs_type_oth

text

Specify other type of legs / feet lesions

[lesion_legs_type(88)]=’1’

Skin

This refers to the type of skin lesions involving the legs and/or feet.

If ‘Other’. Write the type of lesions involving this area, between 00:00 to 24:00 on day of assessment.

1

1

daily

SKIN & MUCOSA ASSESSMENT: Record the information furthest from normal between 00:00 to 24:00 on day of assessment.

lesion_legs_num

text

Number of legs / feet lesions

[lesion_legs]=’1’

Skin

This refers to the number of skin lesions involving the legs and/or feet.

Write the number of lesions involving this area, between 00:00 to 24:00 on day of assessment.

1

1

daily

SKIN & MUCOSA ASSESSMENT: Record the information furthest from normal between 00:00 to 24:00 on day of assessment.

lesion_palm

radio

Are there any lesions on the palms?

1, Yes | 0, No | 99, Unknown

[lesion_skinles]=’1’

Skin

This refers to presence of skin lesions involving the palms.

Indicate ‘Yes’, if there are active lesions involving this area between 00:00 to 24:00 on day of assessment.

1

1

daily

SKIN & MUCOSA ASSESSMENT: Record the information furthest from normal between 00:00 to 24:00 on day of assessment.

lesion_palm_type

checkbox

Type of palm lesions

1, Vesicle | 2, Pustule | 3, Ulcerated lesions | 4, Necrotising lesions | 5, Fungating lesions | 6, Haemorrhagic lesions | 88, Other

[lesion_palm]=’1’

Skin

This refers to the type of skin lesions involving the palms. Vesicle refers to raised lesion and filled with clear fluid. Pustule refers to raised lesion and filed with pus, an opaque fluid. Ulcerated lesion refers to a lesion with break in the skin. Necrotising lesion refers to a lesion with necrotic (dead) tissue. Fungating lesion refers to a lesion from underlying tissues which is breaking through the skin’s surface.

Select the single most appropriate option that represents the type of lesions involving this area, between 00:00 to 24:00 on day of assessment.

1

1

daily

SKIN & MUCOSA ASSESSMENT: Record the information furthest from normal between 00:00 to 24:00 on day of assessment.

lesion_palm_type_oth

text

If other: Specify other type of palm lesions

[lesion_palm_type(88)]=’1’

Skin

This refers to the type of skin lesions involving the palms.

If ‘Other’. Write the type of lesions involving this area, between 00:00 to 24:00 on day of assessment.

1

1

daily

SKIN & MUCOSA ASSESSMENT: Record the information furthest from normal between 00:00 to 24:00 on day of assessment.

lesion_palm_num

text

Number of palm lesions

[lesion_palm]=’1’

Skin

This refers to the number of skin lesions involving the palms.

Write the number of lesions involving this area, between 00:00 to 24:00 on day of assessment.

1

1

daily

SKIN & MUCOSA ASSESSMENT: Record the information furthest from normal between 00:00 to 24:00 on day of assessment.

lesion_sole

radio

Are there any lesions on the soles?

1, Yes | 0, No | 99, Unknown

[lesion_skinles]=’1’

Skin

This refers to presence of skin lesions involving the soles.

Indicate ‘Yes’, if there are active lesions involving this area between 00:00 to 24:00 on day of assessment.

1

1

daily

SKIN & MUCOSA ASSESSMENT: Record the information furthest from normal between 00:00 to 24:00 on day of assessment.

lesion_sole_type

checkbox

Type of sole lesions

1, Vesicle | 2, Pustule | 3, Ulcerated lesions | 4, Necrotising lesions | 5, Fungating lesions | 6, Haemorrhagic lesions | 88, Other

[lesion_sole]=’1’

Skin

This refers to the type of skin lesions involving the soles. Vesicle refers to raised lesion and filled with clear fluid. Pustule refers to raised lesion and filed with pus, an opaque fluid. Ulcerated lesion refers to a lesion with break in the skin. Necrotising lesion refers to a lesion with necrotic (dead) tissue. Fungating lesion refers to a lesion from underlying tissues which is breaking through the skin’s surface.

Select the single most appropriate option that represents the type of lesions involving this area, between 00:00 to 24:00 on day of assessment.

1

1

daily

SKIN & MUCOSA ASSESSMENT: Record the information furthest from normal between 00:00 to 24:00 on day of assessment.

lesion_sole_oth

text

If other: Specify other type of sole lesions

[lesion_sole_type(88)]=’1’

Skin

This refers to the type of skin lesions involving the soles.

If ‘Other’. Write the type of lesions involving this area, between 00:00 to 24:00 on day of assessment.

1

1

daily

SKIN & MUCOSA ASSESSMENT: Record the information furthest from normal between 00:00 to 24:00 on day of assessment.

lesion_sole_num

text

Number of sole lesions

[lesion_sole]=’1’

Skin

This refers to the number of involving the soles.

Write the number of lesions involving this area, between 00:00 to 24:00 on day of assessment.

1

1

daily

SKIN & MUCOSA ASSESSMENT: Record the information furthest from normal between 00:00 to 24:00 on day of assessment.

lesion_genit

radio

Are there any lesions on the external genitalia?

1, Yes | 0, No | 99, Unknown

[lesion_skinles]=’1’

Skin

This refers to presence of skin lesions involving the external genitalia.

Indicate ‘Yes’, if there are active lesions involving this area between 00:00 to 24:00 on day of assessment.

1

1

daily

SKIN & MUCOSA ASSESSMENT: Record the information furthest from normal between 00:00 to 24:00 on day of assessment.

lesion_genit_type

checkbox

Type of external genitalia lesions

1, Vesicle | 2, Pustule | 3, Ulcerated lesions | 4, Necrotising lesions | 5, Fungating lesions | 6, Haemorrhagic lesions | 88, Other

[lesion_genit]=’1’

Skin

This refers to the type of skin lesions involving the external genitalia. Vesicle refers to raised lesion and filled with clear fluid. Pustule refers to raised lesion and filed with pus, an opaque fluid. Ulcerated lesion refers to a lesion with break in the skin. Necrotising lesion refers to a lesion with necrotic (dead) tissue. Fungating lesion refers to a lesion from underlying tissues which is breaking through the skin’s surface.

Select the single most appropriate option that represents the type of lesions involving this area, between 00:00 to 24:00 on day of assessment.

1

1

daily

SKIN & MUCOSA ASSESSMENT: Record the information furthest from normal between 00:00 to 24:00 on day of assessment.

lesion_genit_type_oth

text

If other: Specify other type of external genitalia lesions

[lesion_genit_type(88)]=’1’

Skin

This refers to the type of skin lesions involving the external genitalia.

If ‘Other’. Write the type of lesions involving this area, between 00:00 to 24:00 on day of assessment.

1

1

daily

SKIN & MUCOSA ASSESSMENT: Record the information furthest from normal between 00:00 to 24:00 on day of assessment.

lesion_genit_num

text

Number of external genitalia lesions

[lesion_genit]=’1’

Skin

This refers to the number of involving the external genitalia.

Write the number of lesions involving this area, between 00:00 to 24:00 on day of assessment.

1

1

daily

SKIN & MUCOSA ASSESSMENT: Record the information furthest from normal between 00:00 to 24:00 on day of assessment.

lesion_peri

radio

Are there any perianal lesions?

1, Yes | 0, No | 99, Unknown

[lesion_skinles]=’1’

Skin

This refers to presence of skin lesions involving the perianal region.

Indicate ‘Yes’, if there are active lesions involving this area between 00:00 to 24:00 on day of assessment.

1

1

daily

SKIN & MUCOSA ASSESSMENT: Record the information furthest from normal between 00:00 to 24:00 on day of assessment.

lesion_peri_type

checkbox

Type of perianal lesions

1, Vesicle | 2, Pustule | 3, Ulcerated lesions | 4, Necrotising lesions | 5, Fungating lesions | 6, Haemorrhagic lesions | 88, Other

[lesion_peri]=’1’

Skin

This refers to the type of skin lesions involving the perianal region. Vesicle refers to raised lesion and filled with clear fluid. Pustule refers to raised lesion and filed with pus, an opaque fluid. Ulcerated lesion refers to a lesion with break in the skin. Necrotising lesion refers to a lesion with necrotic (dead) tissue. Fungating lesion refers to a lesion from underlying tissues which is breaking through the skin’s surface.

Select the single most appropriate option that represents the type of lesions involving this area, between 00:00 to 24:00 on day of assessment.

1

1

daily

SKIN & MUCOSA ASSESSMENT: Record the information furthest from normal between 00:00 to 24:00 on day of assessment.

lesion_peri_type_oth

text

Specify other type of perianal lesions

[lesion_peri_type(88)]=’1’

Skin

This refers to the type of skin lesions involving the perianal region.

If ‘Other’. Write the type of lesions involving this area, between 00:00 to 24:00 on day of assessment.

1

1

daily

SKIN & MUCOSA ASSESSMENT: Record the information furthest from normal between 00:00 to 24:00 on day of assessment.

lesion_peri_num

text

Number of perianal lesions

[lesion_peri]=’1’

Skin

This refers to the number of involving the perianal region.

Write the number of lesions involving this area, between 00:00 to 24:00 on day of assessment.

1

1

daily

SKIN & MUCOSA ASSESSMENT: Record the information furthest from normal between 00:00 to 24:00 on day of assessment.

lesion_mouth

radio

Are there any lesions inside the mouth?

1, Yes | 0, No | 99, Unknown

[lesion_mucos]=’1’

This refers to presence of mucosal lesions inside the mouth (oral cavity).

Indicate ‘Yes’, if there are active lesions involving this area between 00:00 to 24:00 on day of assessment.

1

1

daily

SKIN & MUCOSA ASSESSMENT: Record the information furthest from normal between 00:00 to 24:00 on day of assessment.

lesion_mouth_stat

checkbox

Inside mouth lesion status

1, Causing pain | 2, Bleeding or Discharge | 3, Ulceration

[lesion_mouth]=’1’

This refers to the status of mucosal lesions in the mouth (oral cavity). A lesion causing pain is associated with an unpleasant, uncomfortable or painful sensation at the site of the lesion. A lesion which is bleeding or discharging is associated with bleeding from blood vessels or serous / purulent fluid discharge at the site of the lesion. An ulcerated lesion is associated with erosion of the mucous membrane of the mouth, showing local excavation of the surface at the site of the lesion.

Select the single most appropriate option that represents the type of lesions involving this area, between 00:00 to 24:00 on day of assessment.

1

1

daily

SKIN & MUCOSA ASSESSMENT: Record the information furthest from normal between 00:00 to 24:00 on day of assessment.

lesion_vagin

radio

Are there any lesions in the vaginal canal?

1, Yes | 0, No | 99, Unknown

[lesion_mucos]=’1’

This refers to presence of mucosal lesions in the vaginal canal.

Indicate ‘Yes’, if there are active lesions involving this area between 00:00 to 24:00 on day of assessment.

1

1

daily

SKIN & MUCOSA ASSESSMENT: Record the information furthest from normal between 00:00 to 24:00 on day of assessment.

lesion_vagin_stat

checkbox

Vaginal canal lesion status

1, Causing pain | 2, Bleeding or Discharge | 3, Ulceration

[lesion_vagin]=’1’

This refers to the status of mucosal lesions in the vaginal canal. A lesion causing pain is associated with an unpleasant, uncomfortable or painful sensation at the site of the lesion. A lesion which is bleeding or discharging is associated with bleeding from blood vessels or serous / purulent fluid discharge at the site of the lesion. An ulcerated lesion is associated with erosion of the mucous membrane of the mouth, showing local excavation of the surface at the site of the lesion.

Select the single most appropriate option that represents the type of lesions involving this area, between 00:00 to 24:00 on day of assessment.

1

1

daily

SKIN & MUCOSA ASSESSMENT: Record the information furthest from normal between 00:00 to 24:00 on day of assessment.

lesion_rectum

radio

Are there any lesions in the rectum?

1, Yes | 0, No | 99, Unknown

[lesion_mucos]=’1’

This refers to presence of mucosal lesions in the rectum.

Indicate ‘Yes’, if there are active lesions involving this area between 00:00 to 24:00 on day of assessment.

1

1

daily

SKIN & MUCOSA ASSESSMENT: Record the information furthest from normal between 00:00 to 24:00 on day of assessment.

lesion_rectum_stat

checkbox

Rectal lesion status

1, Causing pain | 2, Bleeding or Discharge | 3, Ulceration | 4, Tenesmus

[lesion_rectum]=’1’

This refers to the status of mucosal lesions in the rectum. A lesion causing pain is associated with an unpleasant, uncomfortable or painful sensation at the site of the lesion. A lesion which is bleeding or discharging is associated with bleeding from blood vessels or serous / purulent fluid discharge at the site of the lesion. An ulcerated lesion is associated with erosion of the mucous membrane of the mouth, showing local excavation of the surface at the site of the lesion.

Select the single most appropriate option that represents the type of lesions involving this area, between 00:00 to 24:00 on day of assessment.

1

1

daily

SKIN & MUCOSA ASSESSMENT: Record the information furthest from normal between 00:00 to 24:00 on day of assessment.

lesion_anorec

radio

Ano-rectitis

1, Yes | 0, No | 99, Unknown

[lesion_rectum]=’1’

Gastrointestinal

Defined as inflammation of the mucosal membranes of the anus and/or rectum which can be accompanied by pain or bleeding.

Indicate ‘Yes’, if the patient experienced this at any time during the date of assessment.

SNOMED

SNOMED

C0033246, Proctitis

clinical_features

1

1

daily

SKIN & MUCOSA ASSESSMENT: Record the information furthest from normal between 00:00 to 24:00 on day of assessment.

lesion_penis

radio

Are there any lesions on the penis?

1, Yes | 0, No | 99, Unknown

[lesion_mucos]=’1’

This refers to presence of mucosal lesions on the penis.

Indicate ‘Yes’, if there are active lesions involving this area between 00:00 to 24:00 on day of assessment.

1

1

daily

SKIN & MUCOSA ASSESSMENT: Record the information furthest from normal between 00:00 to 24:00 on day of assessment.

lesion_penis_stat

checkbox

Penile lesion status

1, Causing pain | 2, Bleeding or Discharge | 3, Ulceration

[lesion_penis]=’1’

This refers to the status of mucosal lesions on the penis. A lesion causing pain is associated with an unpleasant, uncomfortable or painful sensation at the site of the lesion. A lesion which is bleeding or discharging is associated with bleeding from blood vessels or serous / purulent fluid discharge at the site of the lesion. An ulcerated lesion is associated with erosion of the mucous membrane of the mouth, showing local excavation of the surface at the site of the lesion.

Select the single most appropriate option that represents the type of lesions involving this area, between 00:00 to 24:00 on day of assessment.

1

1

daily

SKIN & MUCOSA ASSESSMENT: Record the information furthest from normal between 00:00 to 24:00 on day of assessment.

lesion_othsite

radio

Other site(s)

1, Yes | 0, No | 99, Unknown

[lesion_mucos]=’1’

This refers to presence of mucosal lesions involving other site(s).

Indicate ‘Yes’, if there are active lesions involving other site(s) between 00:00 to 24:00 on day of assessment, not specified above.

1

1

daily

SKIN & MUCOSA ASSESSMENT: Record the information furthest from normal between 00:00 to 24:00 on day of assessment.

lesion_othsite_spec

text

Specify other site(s)

[lesion_othsite]=’1’

This refers to presence of mucosal lesions involving other site(s).

If ‘Yes’, write the location of mucosal lesions involving other site(s).

1

1

daily

SKIN & MUCOSA ASSESSMENT: Record the information furthest from normal between 00:00 to 24:00 on day of assessment.

lesion_othstat

checkbox

Other site(s) lesion status

1, Causing pain | 2, Bleeding or Discharge | 3, Ulceration

[lesion_othsite]=’1’

This refers to the status of mucosal lesions involving other site(s). A lesion causing pain is associated with an unpleasant, uncomfortable or painful sensation at the site of the lesion. A lesion which is bleeding or discharging is associated with bleeding from blood vessels or serous / purulent fluid discharge at the site of the lesion. An ulcerated lesion is associated with erosion of the mucous membrane of the mouth, showing local excavation of the surface at the site of the lesion.

Select the single most appropriate option that represents the type of lesions involving this area, between 00:00 to 24:00 on day of assessment.

1

1

daily

SKIN & MUCOSA ASSESSMENT: Record the information furthest from normal between 00:00 to 24:00 on day of assessment.

lesion_24hr

radio

Have new skin or mucosal lesions appeared in the previous 24 hours? (may be best assessed by patients)

1, Yes | 0, No | 99, Unknown

[lesion_dailydata]=’1’

This refers to appearance of a new skin or mucosal lesion(s) in the previous 24-hours.

Indicate ‘Yes’, if new lesions have appeared in the previous 24-hours.

1

1

daily

SKIN & MUCOSA ASSESSMENT: Record the information furthest from normal between 00:00 to 24:00 on day of assessment.

lesion_sl

radio

Estimated total number of skin lesions on the body

0, None | 1, 1 | 2, 2-5 | 3, 6-9 | 4, 10-24 | 5, 25-49 | 6, 50-99 | 7, 100-250 | 8, 251-1000 | 9, >1000

[lesion_dailydata]=’1’

Document only skin lesions related to infection by pathogen of interest. Healed lesions (scab absent, fresh skin present) should not be included. Rash from erythema multiform or any other cause should not be included.

Select the single most appropriate option that best represents the number of skin lesions between 00:00 to 24:00 on day of assessment.

1

1

daily

SKIN & MUCOSA ASSESSMENT: Record the information furthest from normal between 00:00 to 24:00 on day of assessment.

lesion_ml

radio

Estimated total number of mucosal lesions on the body

0, None | 1, 1 | 2, 2-5 | 3, 6-9 | 4, 10-24 | 5, 25-49 | 6, 50-99 | 7, 100-250 | 8, 251-1000 | 9, >1000

[lesion_dailydata]=’1’

Document only mucosal lesions related to infection by pathogen of interest. Healed lesions (scab absent, fresh skin present) should not be included. Rash from erythema multiform or any other cause should not be included.

Select the single most appropriate option that best represents the number of mucosal lesions between 00:00 to 24:00 on day of assessment.

1

1

daily

SKIN & MUCOSA ASSESSMENT: Record the information furthest from normal between 00:00 to 24:00 on day of assessment.

lesion_slpain

radio

Pain at any skin lesion site(s)

1, Yes | 0, No | 99, Unknown

[lesion_dailydata]=’1’

This refers to an unpleasant, uncomfortable or painful sensation at the site(s) of the skin lesion.

Indicate ‘Yes’, if the patient experienced this between 00:00 to 24:00 on day of assessment.

1

1

daily

SKIN & MUCOSA ASSESSMENT: Record the information furthest from normal between 00:00 to 24:00 on day of assessment.

lesion_slpain_score

number

Maximal pain score, where 0 means “no pain”, and 10 means “the worst possible pain.”

number

0

10

[lesion_slpain]=’1’

This refers to the patient’s objective rating of the severity of pain at the site(s) of the lesion, on a scale of 0 to 10. Where 0 represents “no pain” and 10 represents the “worst imaginable pain”.

Indicate the patient’s rating of the severity of the pain at the site(s) of lesion.

1

1

daily

SKIN & MUCOSA ASSESSMENT: Record the information furthest from normal between 00:00 to 24:00 on day of assessment.

lesion_mlpain

radio

Pain at any mucosal lesion site(s)

1, Yes | 0, No | 99, Unknown

[lesion_dailydata]=’1’

This refers to an unpleasant, uncomfortable or painful sensation at the site(s) of the mucosal lesion.

Indicate ‘Yes’, if the patient experienced this between 00:00 to 24:00 on day of assessment.

1

1

daily

SKIN & MUCOSA ASSESSMENT: Record the information furthest from normal between 00:00 to 24:00 on day of assessment.

lesion_mlpain_score

number

Maximal pain score, where 0 means “no pain”, and 10 means “the worst possible pain.”

number

0

10

[lesion_mlpain]=’1’

This refers to the patient’s objective rating of the severity of pain at the site(s) of the lesion, on a scale of 0 to 10. Where 0 represents “no pain” and 10 represents the “worst imaginable pain”.

Indicate the patient’s rating of the severity of the pain at the site(s) of lesion.

1

1

daily

SKIN & MUCOSA ASSESSMENT: Record the information furthest from normal between 00:00 to 24:00 on day of assessment.

lesion_desc

text

Describe any other lesion complication(s)

[lesion_dailydata]=’1’

This refers to other lesion complication(s) which have not been specified above.

Describe other lesion complication(s) that occurred or were first identified between 00:00 to 24:00 on day of assessment, that have not been specified above.

1

1

daily

TREATMENTS & INTERVENTIONS: Record all interventions given between 00:00 to 24:00 on day of assessment.

treat_dailydata

radio

Enter Treatments & Interventions data for this date?

1, Yes | 0, No

This section refers to treatments or interventions that are typically conducted and recorded in the emergency room and/or the ward or acute medical unit to which the patient was admitted between 00:00 and 24:00 hours on day of assessment.

Indicate ‘Yes’, if treatments or interventions were conducted and recorded between 00:00 and 24:00 hours on day of assessment.

1

1

1

1

daily

TREATMENTS & INTERVENTIONS: Record all interventions given between 00:00 to 24:00 on day of assessment.

treat_fluid

radio

Any fluids prescribed

1, Yes | 0, No | 99, Unknown

[treat_dailydata]=’1’

This refers to any prescribed fluids (oral or intravenous), excluding those the patient consumes in a non-prescribed dietary manner.

Indicate ‘Yes’, if the patient was received oral rehydration fluids between 00:00 and 24:00 hours on day of assessment.

C44192, Administration of fluid therapy

1

1

1

daily

TREATMENTS & INTERVENTIONS: Record all interventions given between 00:00 to 24:00 on day of assessment.

treat_fluid_oral

radio

Oral rehydration

1, Yes | 0, No | 99, Unknown

[treat_dailydata]=’1’

This refers to oral (enteral) rehydration fluids, excluding those the patient consumes in a non-prescribed dietary manner.

Indicate ‘Yes’, if the patient received oral rehydration fluids between 00:00 and 24:00 hours on day of assessment.

SNOMED

243222002, Oral rehydration therapy (procedure)

C0029168, Oral Rehydration Therapy

1

1

1

daily

TREATMENTS & INTERVENTIONS: Record all interventions given between 00:00 to 24:00 on day of assessment.

treat_fluid_oralvol

text

Oral rehydration volume (mL/24 hours)

[treat_fluid_oral] = ‘1’

This refers to oral (enteral) rehydration fluids, excluding those the patient consumes in a non-prescribed dietary manner.

If ‘Yes’, record the amount of oral rehydration fluids given between 00:00 and 24:00 on day of assessment in millilitres (mL).

SNOMED

243222002, Oral rehydration therapy (procedure)

C0029168, Oral Rehydration Therapy

1

1

1

daily

TREATMENTS & INTERVENTIONS: Record all interventions given between 00:00 to 24:00 on day of assessment.

treat_fluid_parent

radio

Intravenous (parenteral) fluids

1, Yes | 0, No | 99, Unknown

[treat_dailydata]=’1’

This refers to intravenous fluids, adminstered via a central or peripheral catheter into the venous system, for fluid resuscitation or replacement of electrolytes, calories, vitamins, or other medical reasons. Examples: 0.9% Sodium Chloride (Normal Saline), 5% Glucose (Dextrose 5% in Water), Albumin etc.

Indicate ‘Yes’, if the patient received intravenous fluids between 00:00 and 24:00 hours on the day of assessment.

SNOMED

118431008, Fluid for intravenous administration (substance)

C2735346, Intravenous fluids administered

1

1

1

daily

TREATMENTS & INTERVENTIONS: Record all interventions given between 00:00 to 24:00 on day of assessment.

treat_fluid_parent_type

multi_list

Intravenous fluid type

drugs_IVfluids

[treat_fluid_parent] = ‘1’

This refers to intravenous fluids, adminstered via a central or peripheral catheter into the venous system, for fluid resuscitation or replacement of electrolytes, calories, vitamins, or other medical reasons. Examples: 0.9% Sodium Chloride (Normal Saline), 5% Glucose (Dextrose 5% in Water), Albumin etc.

Select the most appropriate option corresponding to the type of intravenous fluid(s) administered.

SNOMED

118431008, Fluid for intravenous administration (substance)

C2735346, Intravenous fluids administered

1

1

1

daily

TREATMENTS & INTERVENTIONS: Record all interventions given between 00:00 to 24:00 on day of assessment.

treat_fluid_cryst

number

Crystalloid volume (mL/24 hours)

number

0

30000

[treat_fluid_parent] = ‘1’

Crystalloid intravenous fluids refer to aqueous solutions of mineral salts and other small, water-soluble molecules. They are commonly used for fluid replacement or resuscitation. Examples: 0.9% Sodium Chloride (Normal Saline), Lactated Ringer (USP), 5% Glucose (Dextrose 5% in Water) etc.

Record the volume of crystalloid fluids the patient received between 00:00 and 24:00 on day of assessment in millilitres (mL).

C0056562, crystalloid solutions

1

1

daily

TREATMENTS & INTERVENTIONS: Record all interventions given between 00:00 to 24:00 on day of assessment.

treat_fluid_colloid

number

Colloid volume (mL/24 hours)

number

0

10000

[treat_fluid_parent] = ‘1’

Colloid intravenous fluids are solutions containing large molecules, such as proteins or polysaccharides, which remain in the bloodstream for a longer duration compared and help maintain or expand intravascular volume. Examples: albumin, gelatin etc.

Record the volume of colloid fluids the patient received between 00:00 and 24:00 on day of assessment in millilitres (mL).

C3267204, Colloid fluid replacement

1

1

daily

TREATMENTS & INTERVENTIONS: Record all interventions given between 00:00 to 24:00 on day of assessment.

treat_blood

radio

Blood / blood products transfusion

1, Yes | 0, No | 99, Unknown

[treat_dailydata]=’1’

This refers to a transfusion of whole blood or blood products such as packed red blood cells, platelets, fresh-frozen plasma, cryoprecipitate, fibrinogen concentrate, granulocytes etc. Excludes transfusion of human intravenous immunoglobulin.

Indicate ‘Yes’, if the patient received blood product transfusion any time between 00:00 and 24:00 hours on day of assessment. If ‘Yes’ Select the product(s) below.

SNOMED

  1. Transfusion of blood product (procedure)

C0005841, Blood Transfusion

1

1

1

1

daily

TREATMENTS & INTERVENTIONS: Record all interventions given between 00:00 to 24:00 on day of assessment.

treat_blood_type

checkbox

Select all blood products that were administered.

1, Platelets | 2, Cryoprecipitate | 3, Whole blood | 4, Frozen fresh plasma | 5, Fibrinogen concentrate | 6, Packed RBC (red cell concentrate)

[treat_blood] = ‘1’

Platelets refers to the transfer of blood platelets from a donor to a recipient or reinfusion to the donor. Cryoprecipitate refers to a frozen blood product prepared from frozen plasma that contains fibrinogen (factor I), antihemophilic factor (factor VIII), factor XIII, von Willebrand factor (vWF) and fibronectin. Whole blood refers to intravenous administration of whole blood (blood that contains plasma and red blood cells) into an individual. Packed RBC refers to red blood cells from a unit of whole blood following removal of most of the plasma, leaving a unit with a haematocrit of about 6%. Fresh frozen plasma refers to the plasma that is separated from the whole blood and frozen quickly after a blood donation in order to be used for blood transfusions. Fibrinogen concentrate is a haemostatic agent used for the treatment of acute bleeding episodes in patients with congenital fibrinogen deficiency, including afibrinogenemia and hypofibrinogenemia.

Select the most appropriate option(s) corresponding to the blood product(s) that were administered.

SNOMED

180208003, Intravenous blood transfusion of platelets (procedure) | 256401009, Cryoprecipitate (product) | 420135007, Whole blood (substance) | 346447007, Fresh frozen plasma (product) | 23295004, Coagulation factor I (substance) | 431069006, Packed red blood cells (product)

C0086818, Platelet Transfusion | C0443121, Cryoprecipitate (product) | C0370231, whole blood | C0016709, Fresh frozen plasma | C0016006, fibrinogen | C2316467, packed red blood cells

1

1

1

1

daily

TREATMENTS & INTERVENTIONS: Record all interventions given between 00:00 to 24:00 on day of assessment.

treat_blood_plate

text

Platelets (units/24 hours)

[treat_blood_type(1)] = ‘1’

Platelets refers to the transfer of blood platelets from a donor to a recipient or reinfusion to the donor.

Record the number of units the patient received between 00:00 and 24:00 on day of assessment in millilitres (mL).

SNOMED

180208003, Intravenous blood transfusion of platelets (procedure)

C0086818, Platelet Transfusion

1

1

daily

TREATMENTS & INTERVENTIONS: Record all interventions given between 00:00 to 24:00 on day of assessment.

treat_blood_cryo

text

Cryoprecipitate (units/24 hours)

[treat_blood_type(2)]=’1’

Cryoprecipitate refers to a frozen blood product prepared from frozen plasma that contains fibrinogen (factor I), antihemophilic factor (factor VIII), factor XIII, von Willebrand factor (vWF) and fibronectin.Cryoprecipitate refers to a frozen blood product prepared from frozen plasma that contains fibrinogen (factor I), antihemophilic factor (factor VIII), factor XIII, von Willebrand factor (vWF) and fibronectin.

Record the number of units the patient received between 00:00 and 24:00 on day of assessment in millilitres (mL).

SNOMED

256401009, Cryoprecipitate (product)

C0443121, Cryoprecipitate (product)

1

1

daily

TREATMENTS & INTERVENTIONS: Record all interventions given between 00:00 to 24:00 on day of assessment.

treat_blood_whole

text

Whole blood volume (units/24 hours)

[treat_blood_type(3)]=’1’

Whole blood refers to intravenous administration of whole blood (blood that contains plasma and red blood cells) into an individual.

Record the number of units the patient received between 00:00 and 24:00 on day of assessment in millilitres (mL).

SNOMED

420135007, Whole blood (substance)

C0370231, whole blood

1

1

1

1

daily

TREATMENTS & INTERVENTIONS: Record all interventions given between 00:00 to 24:00 on day of assessment.

treat_blood_plasma

text

Frozen fresh plasma (units/24 hours)

[treat_blood_type(4)]=’1’

Fresh frozen plasma refers to the plasma that is separated from the whole blood and frozen quickly after a blood donation in order to be used for blood transfusions.

Record the number of units the patient received between 00:00 and 24:00 on day of assessment in millilitres (mL).

SNOMED

346447007, Fresh frozen plasma (product)

C0016709, Fresh frozen plasma

1

1

daily

TREATMENTS & INTERVENTIONS: Record all interventions given between 00:00 to 24:00 on day of assessment.

treat_blood_fibrin

text

Fibrinogen concentrate (units/24 hours)

[treat_blood_type(5)]=’1’

Fibrinogen concentrate is a haemostatic agent used for the treatment of acute bleeding episodes in patients with congenital fibrinogen deficiency, including afibrinogenemia and hypofibrinogenemia.

Record the number of units the patient received between 00:00 and 24:00 on day of assessment in millilitres (mL).

SNOMED

23295004, Coagulation factor I (substance)

C0016006, fibrinogen

1

1

daily

TREATMENTS & INTERVENTIONS: Record all interventions given between 00:00 to 24:00 on day of assessment.

treat_blood_rcc

text

Packed red blood cells (red cell concentrate) (units/24 hours)

[treat_blood_type(6)]=’1’

Packed RBC refers to red blood cells from a unit of whole blood following removal of most of the plasma, leaving a unit with a haematocrit of about 6%.

Record the number of units the patient received between 00:00 and 24:00 on day of assessment in millilitres (mL).

SNOMED

431069006, Packed red blood cells (product)

C2316467, packed red blood cells

1

1

1

1

daily

TREATMENTS & INTERVENTIONS: Record all interventions given between 00:00 to 24:00 on day of assessment.

treat_intravenim

radio

Intravenous immunoglobulin

1, Yes | 0, No | 99, Unknown

[treat_dailydata]=’1’

This refers to immunoglobulin preparations, containing primarily Immunoglobulin G (IgG), that are used as intravenous infusions. Examples: Octagam®, Intragam P®, KIOVIG®, Flebogamma 5% DIF®, Carimune NF®, Gamunex®, Gammagard S/D®, Gammagard Liquid®, Gammaked® and Privigen®.

Indicate ‘Yes’, if the patient received intravenous immunoglobulin between 00:00 and 24:00 hours on the day of assessment.

SNOMED

C0085297, immunoglobulins, intravenous

1

1

1

daily

TREATMENTS & INTERVENTIONS: Record all interventions given between 00:00 to 24:00 on day of assessment.

treat_plasmapher

radio

Plasmapheresis / plasma exchange

1, Yes | 0, No | 99, Unknown

[treat_dailydata]=’1’

Plasmapheresis (plasma exchange) refers to a procedure that separate and extracts plasma from the peripheral blood while returning the rest of the blood components to the donor.

Indicate ‘Yes’, if the patient received plasmapheresis between 00:00 and 24:00 hours on the day of assessment.

SNOMED

20720000, Plasmapheresis (procedure)

C32134, Plasmapheresis

1

1

daily

TREATMENTS & INTERVENTIONS: Record all interventions given between 00:00 to 24:00 on day of assessment.

treat_antibiotic

radio

Antibiotics

1, Yes | 0, No | 99, Unknown

[treat_dailydata]=’1’

Antibiotic refers to any agent(s) that selectively target bacteria. Topical preparations should not be recorded.

Indicate ‘Yes’, if the patient received antibiotics between 00:00 and 24:00 hours on day of assessment

SNOMED

281789004, Antibiotic therapy (procedure)

C279516, Antibacterial

1

1

daily

TREATMENTS & INTERVENTIONS: Record all interventions given between 00:00 to 24:00 on day of assessment.

treat_steroids

radio

Corticosteroids

1, Yes | 0, No | 99, Unknown

[treat_dailydata]=’1’

Corticosteroids (commonly referred to as ‘steroids’) refers to all types of therapeutic corticosteroid, made in the adrenal cortex (the outer part of the adrenal gland). They are also made in the laboratory. Examples include: prednisolone, prednisone, methyl-prednisolone, dexamethasone, hydrocortisone, fluticasone, betametasone. Topical preparations are not included, but inhaled preparations are included.

Indicate ‘Yes’, if the patient received ‘steroids’ between 00:00 and 24:00 hours on day of assessment.

SNOMED

1290388005, Systemic corticosteroid therapy (procedure)

CL55461, Therapeutic corticosteroid

1

daily

TREATMENTS & INTERVENTIONS: Record all interventions given between 00:00 to 24:00 on day of assessment.

treat_other

radio

Other intervention(s) or procedure(s)

1, Yes | 0, No | 99, Unknown

[treat_dailydata]=’1’

Refers to treatment with corticosteroids via a delivery method that will affect the entire body (oral, intramuscular, intravenous or inhaled). Examples: prednisolone, prednisone, methyl-prednisolone, dexamethasone, hydrocortisone, fluticasone, betametasone. Topical preparations are not included.

Indicate ‘Yes’, if the patient received systemic corticosteroid therapy between 00:00 and 24:00 hours on day of assessment.

SNOMED

1290388005, Systemic corticosteroid therapy (procedure)

CL55461, Therapeutic corticosteroid

1

1

1

daily

TREATMENTS & INTERVENTIONS: Record all interventions given between 00:00 to 24:00 on day of assessment.

treat_other_spec

text

Please specify other intervention(s) or procedure(s)

[treat_other] = ‘1’

This refers to any other specific therapeutic intervention(s) or procedure(s) not otherwise characterised that you believe may be relevant.

Indicate ‘Yes’ if other intervention(s) or procedure(s) were used between 00:00 and 24:00 hours on day of assessment.

SNOMED

C184661, Interventional procedure

1

1

1

1

daily

RESPIRATORY SUPPORT: Record all respiratory interventions given between 00:00 to 24:00 on day of assessment.

treat_o2supp

radio

Supplemental oxygen

1, Yes | 0, No | 99, Unknown

This refers to any method of oxygen therapy that may be delivered via nose cannula, mask or non-invasive or invasive ventilation.

Indicate ‘Yes’, if the patient received supplemental oxygen between 00:00 and 24:00 hours on day of assessment.

SNOMED

57485005, Oxygen therapy (procedure)

C428648, Inspired oxygen concentration

1

1

1

1

1

1

1

daily

RESPIRATORY SUPPORT: Record all respiratory interventions given between 00:00 to 24:00 on day of assessment.

treat_nasalprongs

radio

Nasal prongs

1, Yes | 0, No | 99, Unknown

[treat_o2supp] = ‘1’

This refers to nasal prongs or nasal cannluae which deliver oxygen through two small prongs or cannulae insterted into the nostrils.

Indicate ‘Yes’, if this mode of respiratory support was used to deliver supplemental oxygen to the patient between 00:00 and 24:00 hours on day of assessment.

SNOMED

261974006, Nasal prongs (physical object)

C44587, Nasal prongs

1

1

1

1

1

1

1

daily

RESPIRATORY SUPPORT: Record all respiratory interventions given between 00:00 to 24:00 on day of assessment.

treat_facemask

radio

Face mask

1, Yes | 0, No | 99, Unknown

[treat_o2supp] = ‘1’

This refers to a simple oxygen face mask which is a device placed over a patient’s nose, mouth, or tracheostomy to administer oxygen to the airway.

Indicate ‘Yes’, if this mode of respiratory support was used to deliver supplemental oxygen to the patient between 00:00 and 24:00 hours on day of assessment.

SNOMED

261352009, Face mask (physical object)

C1299377, Oxygen administration by mask

1

1

1

1

1

1

1

daily

RESPIRATORY SUPPORT: Record all respiratory interventions given between 00:00 to 24:00 on day of assessment.

treat_hfno

radio

High flow nasal oxygen

1, Yes | 0, No | 99, Unknown

[treat_o2supp] = ‘1’

This refers to high -flow nasal oxygen therapy which is a non-invasive respiratory support that delivers warmed, humidified, oxygen-enriched air to patients at flow rates greater than those typically delivered by standard-flow oxygen devices.

Indicate ‘Yes’, if this mode of respiratory support was used to deliver supplemental oxygen to the patient between 00:00 and 24:00 hours on day of assessment.

SNOMED

C4761117, High-flow nasal cannula oxygen therapy

1

1

1

1

1

1

1

1

daily

RESPIRATORY SUPPORT: Record all respiratory interventions given between 00:00 to 24:00 on day of assessment.

treat_niv

radio

Non-invasive ventilation

1, Yes | 0, No | 99, Unknown

[treat_o2supp] = ‘1’

This refers to non-invasive ventilation which provides ventilatory support through the patient’s upper airway using a mask or similar device, without the need for tracheal intubation. Examples include Continuous Positive Airway Pressure (CPAP) and Biphasic Continuous Positive Airway Pressure (BiPAP).

Indicate ‘Yes’, if this mode of respiratory support was used to deliver supplemental oxygen to the patient between 00:00 and 24:00 hours on day of assessment.

SNOMED

C1997883, Noninvasive Ventilation

1

1

1

1

1

1

1

1

daily

RESPIRATORY SUPPORT: Record all respiratory interventions given between 00:00 to 24:00 on day of assessment.

treat_niv_type

radio

Type of non-invasive ventilation

1, CPAP | 2, BIPAP | 99, Unknown | 88, Other

[treat_niv]=’1’

This refers to the type of non-invasive respiratory support or ventilation (NIV) used. Continuous positive airway pressure (CPAP) is a technique which uses a continuously maintains airway pressure above atmospheric pressure throughout the respiratory cycle to support spontaneous breathing activity. Biphasic Continuous Positive Airway Pressure (BPAP) uses a time-cycled change of the applied positive airway pressure level to support spontaneous breathing activity.

Select the single most appropriate option corresponding to the type of NIV used between 00:00 and 24:00 hours on day of assessment.

SNOMED

C0199451, Continuous Positive Airway Pressure | C0419004, Dual pressure spontaneous ventilation support’

1

1

1

1

1

1

1

daily

RESPIRATORY SUPPORT: Record all respiratory interventions given between 00:00 to 24:00 on day of assessment.

treat_niv_type_oth

text

Specify other type of non-invasive ventilation

[treat_niv_type]=’88’

This refers to the type of non-invasive respiratory support or ventilation (NIV) used.

If ‘Other’, specify other type of non-invasive ventilation.

1

1

1

1

1

1

1

daily

RESPIRATORY SUPPORT: Record all respiratory interventions given between 00:00 to 24:00 on day of assessment.

treat_imv

radio

Invasive ventilation

1, Yes | 0, No | 99, Unknown

[treat_o2supp] = ‘1’

Thsi refers to invasive mechanical ventilation (IMV) which indicates that patient has undergone tracheal intubation, to mechanically assist or replace spontaneous breathing in patients by use of a powered device that forces oxygenated air into the lungs. The mode of intubation may be orotracheal, nasotracheal, or via a cricothyrotomy or tracheotomy.

Indicate ‘Yes’, if this mode of respiratory support was used to deliver supplemental oxygen to the patient between 00:00 and 24:00 hours on day of assessment.

SNOMED

1258985005, Invasive mechanical ventilation (regime/therapy)

C1868981, Invasive mechanical ventilation

1

1

1

1

1

1

1

1

daily

RESPIRATORY SUPPORT: Record all respiratory interventions given between 00:00 to 24:00 on day of assessment.

treat_ecmo

radio

Extracorporeal life support therapy (ECLS) / Extracorporeal membrane oxygenation (ECMO)

1, Yes | 0, No | 99, Unknown

[treat_o2supp] = ‘1’

This refers to Extracorporeal Membrane Oxygenation (ECMO) also called to as Extracorporeal life support (ECLS) which is application of a life support system that circulates the blood through an oxygenating system, and may consist of a pump, a membrane oxygenator, and a heat exchanger.

Indicate ‘Yes’, if this mode of respiratory support was used to deliver supplemental oxygen to the patient between 00:00 and 24:00 hours on day of assessment.

SNOMED

233573008, Extracorporeal membrane oxygenation (procedure)

C15357, Extracorporeal Membrane Oxygenation

1

1

1

1

1

1

1

daily

RESPIRATORY SUPPORT: Record all respiratory interventions given between 00:00 to 24:00 on day of assessment.

treat_ecmo_type

radio

Type of ECLS / ECMO

1, Veno-venous (VV) | 2, Veno-arterial (VA) | 99, Unknown

[treat_ecmo]=’1’

This refers to the type of Extracorporeal Membrane Oxygenation (ECMO), also called Extracorporeal life support (ECLS). Veno-venous (venous-venous) ECMO / ECLS is used to support the lungs and veno-arterial (venous-arterial) ECLS / ECMO is used to support the lungs and heart.

Select the single most appropriate option corresponding to the type of ECLS / ECMO used between 00:00 and 24:00 hours on day of assessment.

SNOMED

786453001, Venovenous extracorporeal membrane oxygenation (procedure) | 786451004, Venoarterial extracorporeal membrane oxygenation (procedure)

C519299, Venovenous ECMO | C519297, Venoarterial ECMO

1

1

1

1

1

1

1

daily

RESPIRATORY SUPPORT: Record all respiratory interventions given between 00:00 to 24:00 on day of assessment.

treat_prone

radio

Prone positioning

1, Yes | 0, No | 99, Unknown

This refers to prone positioning which is the act of having the patient lying in the prone position to assist ventilation. It may be implemented for patients on invasive ventilation (intubated) as well as non-intubated or self-ventilating patients.

Indicate ‘Yes’, for any patients if they have been in the prone position to aid their ventilation at any time during admission. If ‘Yes’ Indicate what type of ventilation was occurring while prone positioning below.

SNOMED

431182000, Placing subject in prone position (procedure

CL147586, Prone ventilation

1

1

1

1

1

1

daily

RESPIRATORY SUPPORT: Record all respiratory interventions given between 00:00 to 24:00 on day of assessment.

treat_prone_when

radio

When was the prone positioning?

1, During invasive ventilation | 2, Whilst self-ventilating | 99, Unknown

[treat_prone] = ‘1’

This refers to prone positioning which is the act of having the patient lying in the prone position to assist ventilation. It may be implemented for patients on invasive ventilation (intubated) as well as non-intubated or self-ventilating patients.

Specify the type of assisted ventilation administered when the patient was placed in prone position.

SNOMED

431182000, Placing subject in prone position (procedure

CL147586, Prone ventilation

1

1

1

1

1

1

daily

RESPIRATORY SUPPORT: Record all respiratory interventions given between 00:00 to 24:00 on day of assessment.

treat_pao2yn

radio

PaO2 sample type

1, Arterial | 2, Capillary | 3, Venous | 99, Unknown | 0, Not done

This refers to the type of blood sample used to measure partial pressure of oxygen in blood (PaO2) using blood gas analysis.

Select the single most appropriate option corresponding to the type of blood sample used to measure partial pressure of oxygen.

SNOMED

122552005, Arterial blood specimen (specimen) | 28520004, Venous blood specimen (specimen) | 122554006, Capillary blood specimen (specimen)

C444253, Arterial blood specimen | C444255, Venous blood specimen | C444254, Capillary blood specimen (specimen)

1

1

1

1

1

1

1

daily

RESPIRATORY SUPPORT: Record all respiratory interventions given between 00:00 to 24:00 on day of assessment.

treat_pao2

number

PaO2

number

2.53

450

[treat_pao2yn] = ‘1’ or [treat_pao2yn] = ‘2’ or [treat_pao2yn] = ‘3’

Record the lowest PaO2 that was measured between 00:00 and 24:00 hours on day of assessment.

Record the lowest PaO2 that was measured between 00:00 and 24:00 hours on day of assessment.

1

1

1

1

1

1

daily

RESPIRATORY SUPPORT: Record all respiratory interventions given between 00:00 to 24:00 on day of assessment.

treat_pao2_units

radio

PaO2 (select units)

1, mmHg | 2, kPa

units

[treat_pao2yn] = ‘1’ or [treat_pao2yn] = ‘2’ or [treat_pao2yn] = ‘3’

1

1

1

1

1

1

daily

RESPIRATORY SUPPORT: Record all respiratory interventions given between 00:00 to 24:00 on day of assessment.

treat_pao2_kpa

number

PaO2 (kPa)

number

2.53

60

[treat_pao2yn] = ‘1’ or [treat_pao2yn] = ‘2’ or [treat_pao2yn] = ‘3’

Record the lowest PaO2 that was measured between 00:00 and 24:00 hours on day of assessment.

Record the lowest PaO2 (in kPa) that was measured between 00:00 and 24:00 hours on day of assessment.

SNOMED

250546000, Measurement of partial pressure of oxygen in blood (procedure)

C1318112, Partial pressure of oxygen in blood

1

1

1

1

1

daily

RESPIRATORY SUPPORT: Record all respiratory interventions given between 00:00 to 24:00 on day of assessment.

treat_pao2_mmhg

number

PaO2 (mmHg)

number

19

450

[treat_pao2yn] = ‘1’ or [treat_pao2yn] = ‘2’ or [treat_pao2yn] = ‘3’

Record the lowest PaO2 that was measured between 00:00 and 24:00 hours on day of assessment.

Record the lowest PaO2 (in mmHg) that was measured between 00:00 and 24:00 hours on day of assessment.

SNOMED

250546000, Measurement of partial pressure of oxygen in blood (procedure)

C1318112, Partial pressure of oxygen in blood

1

1

1

1

1

daily

RESPIRATORY SUPPORT: Record all respiratory interventions given between 00:00 to 24:00 on day of assessment.

treat_highfio

number

FiO2 at time of PaO2

number

0.21

100

[treat_pao2yn] = ‘1’ or [treat_pao2yn] = ‘2’ or [treat_pao2yn] = ‘3’

This refers to the measured fraction of inspired oxygen (FiO2) delivered at the time of the lowest PaO2 (partial pressure of oxygen in blood).

Write the FiO2 at time of the lowest PaO2 (recorded above) that occurred any time between 00:00 and 24:00 on day of assessment.

SNOMED

250774007, Inspired oxygen concentration (observable entity)

C428648, Inspired oxygen concentration

1

1

1

1

1

1

1

daily

RESPIRATORY SUPPORT: Record all respiratory interventions given between 00:00 to 24:00 on day of assessment.

treat_highfio_units

radio

FiO2 at time of PaO2 (select units)

1, Fraction, 0.21-1.0 | 2, %, 21-100

units

[treat_pao2yn] = ‘1’ or [treat_pao2yn] = ‘2’ or [treat_pao2yn] = ‘3’

SNOMED

250774007, Inspired oxygen concentration (observable entity)

C428648, Inspired oxygen concentration

1

1

1

1

1

1

1

daily

RESPIRATORY SUPPORT: Record all respiratory interventions given between 00:00 to 24:00 on day of assessment.

treat_highfio_02110

number

FiO2 at time of PaO2 (Fraction, 0.21-1.0)

number

0.21

1

[treat_pao2yn] = ‘1’ or [treat_pao2yn] = ‘2’ or [treat_pao2yn] = ‘3’

This refers to the measured fraction of inspired oxygen (FiO2) delivered at the time of the lowest PaO2 (partial pressure of oxygen in blood).

Write the FiO2 at time of the lowest PaO2 (recorded above), expressed as a fraction, that occurred any time between 00:00 and 24:00 on day of assessment.

SNOMED

250774007, Inspired oxygen concentration (observable entity)

C428648, Inspired oxygen concentration

1

1

1

1

1

daily

RESPIRATORY SUPPORT: Record all respiratory interventions given between 00:00 to 24:00 on day of assessment.

treat_highfio_pcnt

number

FiO2 at time of PaO2 (%, 21-100)

number

21

100

[treat_pao2yn] = ‘1’ or [treat_pao2yn] = ‘2’ or [treat_pao2yn] = ‘3’

This refers to the measured fraction of inspired oxygen (FiO2) delivered at the time of the lowest PaO2 (partial pressure of oxygen in blood).

Write the FiO2 at time of the lowest PaO2 (recorded above), expressed as a percentage, that occurred any time between 00:00 and 24:00 on day of assessment.

SNOMED

250774007, Inspired oxygen concentration (observable entity)

C428648, Inspired oxygen concentration

1

1

1

1

1

daily

RESPIRATORY SUPPORT: Record all respiratory interventions given between 00:00 to 24:00 on day of assessment.

treat_o2supp_oth

radio

Other respiratory support intervention(s) or procedure(s)

1, Yes | 0, No | 99, Unknown

This refers to any other specific respiratory support intervention(s) or procedure(s) not otherwise characterised that you believe may be relevant.

Indicate ‘Yes’ if other respiratory support intervention(s) or procedure(s) were used between 00:00 and 24:00 hours on day of assessment.

SNOMED

C184661, Interventional procedure

1

1

1

1

1

1

daily

RESPIRATORY SUPPORT: Record all respiratory interventions given between 00:00 to 24:00 on day of assessment.

treat_o2supp_oth_spec

text

Please specify other respiratory support intervention(s) or procedure(s)

[treat_o2supp_oth] = ‘1’

This refers to any other specific respiratory support intervention(s) or procedure(s) not otherwise characterised that you believe may be relevant.

If ‘Yes’, please specify the respiratory support intervention(s) or procedure(s) not otherwise characterised that you believe may be relevant.

SNOMED

C184661, Interventional procedure

1

1

1

1

1

1

daily

ADVANCED CARE INTERVENTIONS: Record all advanced care interventions given between 00:00 to 24:00 on day of assessment.

critd_critcare

radio

Were advanced care (including acute organ support and critical care) therapeutic interventions administered on this date?

1, Yes | 0, No | 99, Unknown

This refers to any advanced care (including acute organ support and critical care) therapeutic intervention(s) that were administered between 00:00 and 24:00 hours on day of assessment. This section does not include any respiratory organ support intervention(s), which are recorded seperately.

Indicate ‘Yes’, if any advanced care (including acute organ support and critical care) therapeutic intervention(s) or procedure(s) were administered between 00:00 and 24:00 hours on day of assessment.

1

1

1

1

1

1

1

daily

ADVANCED CARE INTERVENTIONS: Record all advanced care interventions given between 00:00 to 24:00 on day of assessment.

critd_icu

radio

ICU / ITU / HDU / Intermediate Care Unit admission

1, Yes | 0, No | 99, Unknown

[critd_critcare]=’1’

This refers to admission of the patient to intensive care units (ICU), intensive therapy/treatment units (ITU), critical care units, high dependency units (HDU) or unit of similar level between 00:00 and 24:00 hours on day of assessment.

Indicate ‘Yes’, if the patient was admitted to ICU (or unit of similar level) between 00:00 and 24:00 hours on day of assessment.

SNOMED

305351004, Admission to intensive care unit (procedure)

1

1

1

1

1

1

1

daily

ADVANCED CARE INTERVENTIONS: Record all advanced care interventions given between 00:00 to 24:00 on day of assessment.

critd_neuromusc

radio

Neuromuscular blocking agents

1, Yes | 0, No | 99, Unknown

[critd_critcare]=’1’

This refers to the use of neuromuscular blockers between 00:00 and 24:00 hours on day of assessment.. Examples include Atracurium, Cisatracurium, Nimbex etc.

Indicate ‘Yes’, if neuromuscular blockers were used between 00:00 and 24:00 hours on day of assessment.

SNOMED

373295003, Neuromuscular blocking agent (substance)

C27866, Neuromuscular Blocking Agents

1

1

1

1

1

1

1

daily

ADVANCED CARE INTERVENTIONS: Record all advanced care interventions given between 00:00 to 24:00 on day of assessment.

critd_nitricoxide

radio

Inhaled nitric oxide

1, Yes | 0, No | 99, Unknown

[critd_critcare]=’1’

This refers to nitric oxide adminstered as in inhalant, typically used to manage hypoxic respiratory failure in patients.

Indicate ‘Yes’ if inhaled nitric oxide was used any time between 00:00 and 24:00 hours on day of assessment.

SNOMED

1255879001, Administration of nitric oxide (procedure)

C1135443, Administration of inhaled nitric oxide

1

1

1

1

1

1

1

daily

ADVANCED CARE INTERVENTIONS: Record all advanced care interventions given between 00:00 to 24:00 on day of assessment.

critd_tracheostmy

radio

Tracheostomy inserted

1, Yes | 0, No | 99, Unknown

[critd_critcare]=’1’

This refers to the surgical formation of an opening into the trachea through the neck, or the opening so created.

Indicate ‘Yes’ if a tracheostomy was inserted at any time between 00:00 and 24:00 on day of assessment.

SNOMED

232685002, Insertion of tracheostomy tube (procedure)

C39663, Insertion of tracheostomy tube

1

1

1

1

1

1

daily

ADVANCED CARE INTERVENTIONS: Record all advanced care interventions given between 00:00 to 24:00 on day of assessment.

critd_rtt

radio

Renal replacement therapy (RRT) or dialysis / hemofiltration

1, Yes | 0, No | 99, Unknown

[critd_critcare]=’1’

This refers to treatments that substitute for the blood-filtering function of the kidneys. They may be adminstered to patients intermittently or continuously and include dialysis (hemodialysis or peritoneal dialysis), hemofiltration, and hemodiafiltration.

Indicate ‘Yes’ if renal replacement therapy was done any time between 00:00 and 24:00 on day of assessment.

SNOMED

714749008, Continuous renal replacement therapy (procedure)

C3649547, Continuous Renal Replacement Therapy | C5197699, Prolonged Intermittent Renal Replacement Therapy

1

1

1

1

1

1

1

1

daily

ADVANCED CARE INTERVENTIONS: Record all advanced care interventions given between 00:00 to 24:00 on day of assessment.

critd_rtt_typ

radio

Type of renal replacement therapy (RRT) or dialysis / hemofiltration

1, Intermittent | 2, Continuous | 99, Unknown

[critd_rtt]=’1’

This refers to the mode of administering renal replacement therapy (RRT) (dialysis (hemodialysis or peritoneal dialysis), hemofiltration, or hemodiafiltration). Intermittent RRT refers to procedures with non-continuous blood purification via vascular access by increasing blood flow rate. Continuous RRT refers to procedures with continuous blood purification via vascular access designed to mimic kidney function in kidney diseases.

Select the single most appropriate option corresponding to the type of renal replacement therapy (RRT) or dialysis / hemofiltration.

SNOMED

714749008, Continuous renal replacement therapy (procedure) | 895382009, Prolonged intermittent renal replacement therapy (procedure)

C3649547, Continuous Renal Replacement Therapy | C5197699, Prolonged Intermittent Renal Replacement Therapy

1

1

1

1

1

1

1

1

daily

ADVANCED CARE INTERVENTIONS: Record all advanced care interventions given between 00:00 to 24:00 on day of assessment.

critd_vasopress

radio

Any vasopressor / inotropic support

1, Yes | 0, No | 99, Unknown

[critd_critcare]=’1’

This refers to continuous use of a vasopressor or inotrope for at least one hour. A vasopressor is a pharmaceutical agent that causes vasoconstriction. Examples: norepinephrine, epinephrine, vasopressin, terlipressin and phenylephrine. An inotrope is a pharmaceutical agent that alters the force of myocardial contractility. Examples of common ‘positive’ inotropes: dobutamine, dopamine, milrinone and epinephrine.

Indicate ‘Yes’, if this agent was used for at least one hour between 00:00 and 24:00 hours on day of assessment. Indicate the amount used below.

SNOMED

870386000, Vasopressor therapy (procedure)

C5396785, Vasopressor therapy | C588944, Inotropic therapy

1

1

1

1

1

1

1

1

1

daily

ADVANCED CARE INTERVENTIONS: Record all advanced care interventions given between 00:00 to 24:00 on day of assessment.

critd_vasopress_reas

checkbox

Reason for vasopressor / inotrope use

1, Shock | 2, Persistent hypotension | 88, Other | 99, Unknown

[critd_vasopress] = ‘1’

This refers to the reason for vasopressor or inotrope use. Shock is defined as circulatory failure with inadequate oxygen delivery to tissues and is assessed by measuring objective haemodynamic parameters, including pulse pressure, systolic blood pressure, and clinical sigs of hypoperfusion. A patient is classified as having shock if they meet the following objective haemodynamic markers: EITHER - pulse pressure <= 20mmHg or shock index (heart rate / SBP) >= 1.0 in adults and children > 5 years; OR SBP below absolute cutoffs: adults SBP < 90mmHg or MAP < 60; children < 1 year: SBP <70 mmHg; 1-10 years: SBP < [70 + (2 * age in years)]mmHg; > 10 years: SBP < 90mmHg; AND objective evidence of hypoperfusion with at least one of the following: peripheral CRT > 2s; urine output < 0.5 ml/kg/hr for >= 6 hours (if feasible); cold/clammy peripheries; or agitation or altered mental state. Persistent hypotension is confirmed when additional fluid boluses (>= 10ml/kg per bolus) or continuous IV fluids at >= 2 times maintenance rate are required (patients whose hypotension resolves after a single bolus or those with hypotension due to non-infectious causes (e.g. haemorrhage, cardiogenic shock) are excluded from this definition).

Select the most appropriate option(s) which represent the reason(s) for vasopressor / inotrope use.

1

1

1

1

daily

ADVANCED CARE INTERVENTIONS: Record all advanced care interventions given between 00:00 to 24:00 on day of assessment.

critd_vasopress_reasoth

text

Specify other reason for vaspressor / inotrope use

[critd_vasopress_reas(88)] = ‘1’

This refers to the reason for vasopressor or inotrope use.

If ‘Other’, specify the reason for vasopressor or inotrope use.

1

1

1

1

daily

ADVANCED CARE INTERVENTIONS: Record all advanced care interventions given between 00:00 to 24:00 on day of assessment.

critd_vasopress1

radio

Dopamine < 5ug/kg/min OR dobutamine OR milrinone OR levosimendan

1, Yes | 0, No | 99, Unknown

[critd_vasopress] = ‘1’

This refers to the type of vasopressors used.

Indicate ‘Yes’, if this agent(s) was used for at least one hour between 00:00 and 24:00 hours on day of assessment.

1

1

daily

ADVANCED CARE INTERVENTIONS: Record all advanced care interventions given between 00:00 to 24:00 on day of assessment.

critd_vasopress2

radio

Dopamine 5-15ug/kg/min OR epinephrine(adrenaline) / norepinephrine(noradrenaline) <0.1ug/kg/min OR vasopressin OR phenylephrine

1, Yes | 0, No | 99, Unknown

[critd_vasopress] = ‘1’

This refers to the type of vasopressors used.

Indicate ‘Yes’, if this agent(s) was used for at least one hour between 00:00 and 24:00 hours on day of assessment.

1

1

daily

ADVANCED CARE INTERVENTIONS: Record all advanced care interventions given between 00:00 to 24:00 on day of assessment.

critd_vasopress3

radio

Dopamine >15ug/kg/min OR epinephrine(adrenaline) / norepinephrine(noradrenaline) >0 .1ug/kg/min

1, Yes | 0, No | 99, Unknown

[critd_vasopress] = ‘1’

This refers to the type of vasopressors used.

Indicate ‘Yes’, if this agent(s) was used for at least one hour between 00:00 and 24:00 hours on day of assessment.

1

1

daily

ADVANCED CARE INTERVENTIONS: Record all advanced care interventions given between 00:00 to 24:00 on day of assessment.

critd_vasopress_type

checkbox

Vasopressor / Inotropic support type

1, Dopamine (<5ug/kg/min) | 2, Dopamine (5-15ug/kg/min) | 3, Dopamine (>15ug/kg/min) | 4, Norepinephrine (noradrenaline) < 0.1ug/kg/min | 5, Norepinephrine (noradrenaline) > 0.1ug/kg/min |6, Epinephrine (adrenaline) | 7, Dobutamine | 8, Milrinone | 9, Levosimendan | 10, Vasopressin|11,Phenylephrine| 12,Terlipressin |13,Angiotensin-II

[critd_vasopress] = ‘1’

This refers to the type of vasopressors used.

Select the most appropriate option(s) if these agent(s) were used for at least one hour between 00:00 and 24:00 hours on day of assessment.

1

1

1

1

1

1

1

daily

ADVANCED CARE INTERVENTIONS: Record all advanced care interventions given between 00:00 to 24:00 on day of assessment.

critd_critcareunlst

radio

Other advanced care intervention(s) or procedure(s)

1, Yes | 0, No | 99, Unknown

[critd_critcare]=’1’

This refers to any other specific advanced care (including acute organ support and critical care) therapeutic intervention(s) or procedure(s) not otherwise characterised that you believe may be relevant.

Indicate ‘Yes’ if other advanced care intervention(s) or procedure(s) were used between 00:00 and 24:00 hours on day of assessment.

1

1

1

daily

ADVANCED CARE INTERVENTIONS: Record all advanced care interventions given between 00:00 to 24:00 on day of assessment.

critd_critcareunlst_oth

text

Please specify other advanced care intervention(s) or procedure(s)

[critd_critcareunlst] = ‘1’

This refers to any other advanced care (including acute organ support and critical care) therapeutic intervention(s) or procedure(s) not otherwise characterised that you believe may be relevant.

If ‘Yes’, please specify the advanced care therapeutic intervention(s) or procedure(s)not otherwise characterised that you believe may be relevant.

1

1

1

daily

LABORATORY RESULTS: Record the value furthest from normal range between 00:00 to 24:00 on day of assessment.

labs_dailydata

radio

Enter Laboratory Results data for this date?

1, Yes | 0, No

This section refers only to laboratory tests performed at the time the patient stayed in the clinical facility (hospital) and collected on the date of assessment. In general, results that were rejected by the clinical team (e.g. haemolysed blood samples, contaminated microbiology results) should not be reported.

Indicate ‘Yes’, if laboratory samples were taken on the date of assessment. If no laboratory samples were taken on the date of assessment indicate ‘No’ and skip to the next section. In general, do not report results that have been rejected by the clinical team (e.g. haemolysed sample). Unless otherwise specified, if there are multiple measurements, please report the measure furthest from the normal physiological or laboratory range between 00:00 and 24:00 hours on day of assessment.

1

1

1

1

1

1

1

1

1

daily

LABORATORY RESULTS: Record the value furthest from normal range between 00:00 to 24:00 on day of assessment.

labs_fbc

descriptive

Full blood count

[labs_dailydata]=’1’

This refers to results from full blood count.

Indicate ‘Yes’ to enter full blood count results.

1

1

1

1

1

1

1

1

daily

LABORATORY RESULTS: Record the value furthest from normal range between 00:00 to 24:00 on day of assessment.

labs_haemo

number

Haemoglobin

number

0

2000

[labs_dailydata]=’1’

Full Blood Count

Refers to the haemoglobin concentration in blood.

Write haemoglobin concentration level. If there are multiple, report the measure furthest from the normal physiological or laboratory range between 00:00 and 24:00 hours on day of assessment.

clinical_features

1

1

1

1

1

1

1

1

1

1

daily

LABORATORY RESULTS: Record the value furthest from normal range between 00:00 to 24:00 on day of assessment.

labs_haemo_units

radio

Haemoglobin (select units)

1, g/dL | 2, g/L

units

[labs_dailydata]=’1’

Full Blood Count

clinical_features

1

1

1

1

1

1

1

1

1

daily

LABORATORY RESULTS: Record the value furthest from normal range between 00:00 to 24:00 on day of assessment.

labs_haemo_gdl

number

Haemoglobin (g/dL)

number

0

200

[labs_dailydata]=’1’

Full Blood Count

Refers to the haemoglobin concentration in blood.

Write haemoglobin concentration level (g/dL). If there are multiple, report the measure furthest from the normal physiological or laboratory range between 00:00 and 24:00 hours on day of assessment.

SNOMED

250220000, Hemoglobin finding (finding)

C0518015, Hemoglobin measurement

clinical_features

1

1

1

1

1

1

1

1

daily

LABORATORY RESULTS: Record the value furthest from normal range between 00:00 to 24:00 on day of assessment.

labs_haemo_gl

number

Haemoglobin (g/L)

number

0

2000

[labs_dailydata]=’1’

Full Blood Count

Refers to the haemoglobin concentration in blood.

Write haemoglobin concentration level (g/L). If there are multiple, report the measure furthest from the normal physiological or laboratory range between 00:00 and 24:00 hours on day of assessment.

SNOMED

250220000, Hemoglobin finding (finding)

C0518015, Hemoglobin measurement

clinical_features

1

1

1

1

1

1

1

1

daily

LABORATORY RESULTS: Record the value furthest from normal range between 00:00 to 24:00 on day of assessment.

labs_wbccount

number

White blood cell (WBC) count (10^9/L)

number

0

300

[labs_dailydata]=’1’

Full Blood Count

Refers to the total white blood cell count in blood.

Write the total white blood cell (WBC) count (10^9/L). If there are multiple, report the measure furthest from the normal physiological or laboratory range between 00:00 and 24:00 hours on day of assessment.

SNOMED

767002, White blood cell count (procedure)

C0023508, White Blood Cell Count procedure

clinical_features

1

1

1

1

1

1

1

1

1

daily

LABORATORY RESULTS: Record the value furthest from normal range between 00:00 to 24:00 on day of assessment.

labs_neutrophil

number

Neutrophils

number

0

100

[labs_dailydata]=’1’

Full Blood Count

Refers to the neutrophil count in blood.

Write the neutrophil count. If there are multiple, report the measure furthest from the normal physiological or laboratory range between 00:00 and 24:00 hours on day of assessment.

clinical_features

1

1

1

1

1

1

1

1

1

daily

LABORATORY RESULTS: Record the value furthest from normal range between 00:00 to 24:00 on day of assessment.

labs_neutrophil_units

radio

Neutrophils (select units)

1, % | 2, 10^9/L

units

[labs_dailydata]=’1’

Full Blood Count

clinical_features

1

1

1

1

1

1

1

1

daily

LABORATORY RESULTS: Record the value furthest from normal range between 00:00 to 24:00 on day of assessment.

labs_neutrophil_109l

number

Neutrophils (10^9/L)

number

0.2

50

[labs_dailydata]=’1’

Full Blood Count

Refers to the neutrophil count in blood.

Write the neutrophil count (10^9/L). If there are multiple, report the measure furthest from the normal physiological or laboratory range between 00:00 and 24:00 hours on day of assessment.

SNOMED

30630007, Neutrophil count (procedure)

C0200633, Neutrophil count (procedure)

clinical_features

1

1

1

1

1

1

1

daily

LABORATORY RESULTS: Record the value furthest from normal range between 00:00 to 24:00 on day of assessment.

labs_neutrophil_pcnt

number

Neutrophils (%)

number

0

100

[labs_dailydata]=’1’

Full Blood Count

Refers to the neutrophil count in blood.

Write the neutrophil count (%). If there are multiple, report the measure furthest from the normal physiological or laboratory range between 00:00 and 24:00 hours on day of assessment.

SNOMED

30630007, Neutrophil count (procedure)

C0200633, Neutrophil count (procedure)

clinical_features

1

1

1

1

1

1

1

daily

LABORATORY RESULTS: Record the value furthest from normal range between 00:00 to 24:00 on day of assessment.

labs_lymphocyte

number

Lymphocytes

number

0

100

[labs_dailydata]=’1’

Full Blood Count

Refers to the lymphocyte count in blood.

Write the Lymphocyte count. If there are multiple, report the measure furthest from the normal physiological or laboratory range between 00:00 and 24:00 hours on day of assessment.

clinical_features

1

1

1

1

1

1

1

1

1

daily

LABORATORY RESULTS: Record the value furthest from normal range between 00:00 to 24:00 on day of assessment.

labs_lymphocyte_units

radio

Lymphocytes (select units)

1, % | 2, 10^9/L

units

[labs_dailydata]=’1’

Full Blood Count

clinical_features

1

1

1

1

1

1

1

1

daily

LABORATORY RESULTS: Record the value furthest from normal range between 00:00 to 24:00 on day of assessment.

labs_lymphocyte_109l

number

Lymphocytes (10^9/L)

number

0.1

15

[labs_dailydata]=’1’

Full Blood Count

Refers to the lymphocyte count in blood.

Write the Lymphocyte count (10^9/L). If there are multiple, report the measure furthest from the normal physiological or laboratory range between 00:00 and 24:00 hours on day of assessment.

SNOMED

74765001, Lymphocyte count (procedure)

C0200635, Lymphocyte count (procedure)

clinical_features

1

1

1

1

1

1

1

daily

LABORATORY RESULTS: Record the value furthest from normal range between 00:00 to 24:00 on day of assessment.

labs_lymphocyte_pcnt

number

Lymphocytes (%)

number

0

100

[labs_dailydata]=’1’

Full Blood Count

Refers to the lymphocyte count in blood.

Write the Lymphocyte count (%). If there are multiple, report the measure furthest from the normal physiological or laboratory range between 00:00 and 24:00 hours on day of assessment.

SNOMED

74765001, Lymphocyte count (procedure)

C0200635, Lymphocyte count (procedure)

clinical_features

1

1

1

1

1

1

1

daily

LABORATORY RESULTS: Record the value furthest from normal range between 00:00 to 24:00 on day of assessment.

labs_eosinophil

number

Eosinophils

number

0

100

[labs_dailydata]=’1’

Full Blood Count

Refers to the eosinophil count in blood.

Write the eosinophil count. If there are multiple, report the measure furthest from the normal physiological or laboratory range between 00:00 and 24:00 hours on day of assessment.

clinical_features

1

1

1

1

1

1

1

daily

LABORATORY RESULTS: Record the value furthest from normal range between 00:00 to 24:00 on day of assessment.

labs_eosinophil_units

radio

Eosinophils (select units)

1, % | 2, 10^9/L

units

[labs_dailydata]=’1’

Full Blood Count

clinical_features

1

1

1

1

1

1

daily

LABORATORY RESULTS: Record the value furthest from normal range between 00:00 to 24:00 on day of assessment.

labs_eosinophil_109l

number

Eosinophils (10^9/L)

number

0

5

[labs_dailydata]=’1’

Full Blood Count

Refers to the eosinophil count in blood.

Write the eosinophil count (10^9/L). If there are multiple, report the measure furthest from the normal physiological or laboratory range between 00:00 and 24:00 hours on day of assessment.

SNOMED

71960002, Eosinophil count (procedure)

C0200638, Eosinophil count (procedure)

clinical_features

1

1

1

1

1

daily

LABORATORY RESULTS: Record the value furthest from normal range between 00:00 to 24:00 on day of assessment.

labs_eosinophil_pcnt

number

Eosinophils (%)

number

0

100

[labs_dailydata]=’1’

Full Blood Count

Refers to the eosinophil count in blood.

Write the eosinophil count (%). If there are multiple, report the measure furthest from the normal physiological or laboratory range between 00:00 and 24:00 hours on day of assessment.

SNOMED

71960002, Eosinophil count (procedure)

C0200638, Eosinophil count (procedure)

clinical_features

1

1

1

1

1

daily

LABORATORY RESULTS: Record the value furthest from normal range between 00:00 to 24:00 on day of assessment.

labs_hematocrit

number

Haematocrit

number

0

100

[labs_dailydata]=’1’

Full Blood Count

Haematocrit (Ht or HCT), also known as packed cell volume (PCV) or erythrocyte volume fraction (EVF), is the volume of red blood cells in a blood specimen.

Write the haematocrit. If there are multiple, report the measure furthest from the normal physiological or laboratory range between 00:00 and 24:00 hours on day of assessment.

clinical_features

1

1

1

1

1

1

1

1

1

1

daily

LABORATORY RESULTS: Record the value furthest from normal range between 00:00 to 24:00 on day of assessment.

labs_hematocrit_units

radio

Haematocrit (select units)

1, % | 2, L/L

units

[labs_dailydata]=’1’

Full Blood Count

clinical_features

1

1

1

1

1

1

1

1

1

daily

LABORATORY RESULTS: Record the value furthest from normal range between 00:00 to 24:00 on day of assessment.

labs_hematocrit_pcnt

number

Haematocrit (%)

number

0

100

[labs_dailydata]=’1’

Full Blood Count

Haematocrit (Ht or HCT), also known as packed cell volume (PCV) or erythrocyte volume fraction (EVF), is the volume of red blood cells in a blood specimen.

Write the haematocrit (%). If there are multiple, report the measure furthest from the normal physiological or laboratory range between 00:00 and 24:00 hours on day of assessment.

SNOMED

365618006, Finding of hematocrit - packed cell volume level (finding)

C0518014, Hematocrit level

clinical_features

1

1

1

1

1

1

1

1

daily

LABORATORY RESULTS: Record the value furthest from normal range between 00:00 to 24:00 on day of assessment.

labs_hematocrit_ll

number

Haematocrit (L/L)

number

0

1

[labs_dailydata]=’1’

Full Blood Count

Haematocrit (Ht or HCT), also known as packed cell volume (PCV) or erythrocyte volume fraction (EVF), is the volume of red blood cells in a blood specimen.

Write the haematocrit (L/L). If there are multiple, report the measure furthest from the normal physiological or laboratory range between 00:00 and 24:00 hours on day of assessment.

SNOMED

365618006, Finding of hematocrit - packed cell volume level (finding)

C0518014, Hematocrit level

clinical_features

1

1

1

1

1

1

1

1

daily

LABORATORY RESULTS: Record the value furthest from normal range between 00:00 to 24:00 on day of assessment.

labs_platelets

number

Platelets

number

0

1659

[labs_dailydata]=’1’

Full Blood Count

Refers to the platelet count in blood.

Write the platelet count. If there are multiple, report the measure furthest from the normal physiological or laboratory range between 00:00 and 24:00 hours on day of assessment.

clinical_features

1

1

1

1

1

1

1

1

1

1

1

daily

LABORATORY RESULTS: Record the value furthest from normal range between 00:00 to 24:00 on day of assessment.

labs_platelets_units

radio

Platelets (select units)

1, 10^9/L | 2, 10^3/µL

units

[labs_dailydata]=’1’

Full Blood Count

clinical_features

1

1

1

1

1

1

1

1

1

1

daily

LABORATORY RESULTS: Record the value furthest from normal range between 00:00 to 24:00 on day of assessment.

labs_platelets_109l

number

Platelets (10^9/L)

number

0

1659

[labs_dailydata]=’1’

Full Blood Count

Refers to the platelet count in blood.

Write the platelet count (10^9/L). If there are multiple, report the measure furthest from the normal physiological or laboratory range between 00:00 and 24:00 hours on day of assessment.

SNOMED

365632008, Finding of platelet count (finding)

C0032181, Platelet count (procedure)

clinical_features

1

1

1

1

1

1

1

1

1

daily

LABORATORY RESULTS: Record the value furthest from normal range between 00:00 to 24:00 on day of assessment.

labs_platelets_103ul

number

Platelets (10^3/µL)

number

0

1659

[labs_dailydata]=’1’

Full Blood Count

Refers to the platelet count in blood.

Write the platelet count (10^3/L). If there are multiple, report the measure furthest from the normal physiological or laboratory range between 00:00 and 24:00 hours on day of assessment.

SNOMED

365632008, Finding of platelet count (finding)

C0032181, Platelet count (procedure)

clinical_features

1

1

1

1

1

1

1

1

1

daily

LABORATORY RESULTS: Record the value furthest from normal range between 00:00 to 24:00 on day of assessment.

labs_erymeancorvol

number

Ery. mean corpuscular volume (MCV) (fL)

number

0

150

[labs_dailydata]=’1’

Full Blood Count

Refers to the average volume of a red blood cell in a blood specimen.

Write the MCV (fL)

SNOMED

104133003, Erythrocyte mean corpuscular volume determination (procedure)

C0524587, Mean Corpuscular Volume

clinical_features

daily

LABORATORY RESULTS: Record the value furthest from normal range between 00:00 to 24:00 on day of assessment.

labs_erymeancorhgb

number

Ery. mean corpuscular haemoglobin concentration (MCHC)

number

0

450

[labs_dailydata]=’1’

Full Blood Count

Refers to the average concentration of hemoglobin per red blood cell in a blood specimen.

Write the mean corpuscular hemaglobin concentration.

daily

LABORATORY RESULTS: Record the value furthest from normal range between 00:00 to 24:00 on day of assessment.

labs_erymeancorhgb_units

radio

Ery. mean corpuscular haemoglobin concentration (MCHC) (select units)

1, g/L | 2, g/dL

units

[labs_dailydata]=’1’

Full Blood Count

daily

LABORATORY RESULTS: Record the value furthest from normal range between 00:00 to 24:00 on day of assessment.

labs_erymeancorhgb_gl

number

Ery. mean corpuscular haemoglobin concentration (MCHC) (g/L)

number

0

450

[labs_dailydata]=’1’

Full Blood Count

Refers to the average concentration of hemoglobin per red blood cell in a blood specimen.

Write the mean corpuscular hemaglobin concentration (g/L).

SNOMED

37254006, Mean corpuscular hemoglobin concentration determination (procedure)

C0474535, Mean corpuscular hemoglobin concentration determination

clinical_features

daily

LABORATORY RESULTS: Record the value furthest from normal range between 00:00 to 24:00 on day of assessment.

labs_erymeancorhgb_gdl

number

Ery. mean corpuscular haemoglobin concentration (MCHC) (g/dL)

number

0

45

[labs_dailydata]=’1’

Full Blood Count

Refers to the average concentration of hemoglobin per red blood cell in a blood specimen.

Write the mean corpuscular hemaglobin concentration (g/dL).

SNOMED

37254006, Mean corpuscular hemoglobin concentration determination (procedure)

C0474535, Mean corpuscular hemoglobin concentration determination

clinical_features

daily

LABORATORY RESULTS: Record the value furthest from normal range between 00:00 to 24:00 on day of assessment.

labs_erymeancorhe

number

Ery. mean corpuscular haemoglobin (MCH) (pg)

number

0

45

[labs_dailydata]=’1’

Full Blood Count

Refers to the average amount (mass) of hemoglobin per red blood cell in a blood specimen.

Write the mean corpuscular hemaglobin concentration (pg).

SNOMED

54706004, Mean corpuscular hemoglobin determination (procedure)

C0369183, Mean corpuscular hemoglobin determination

clinical_features

daily

LABORATORY RESULTS: Record the value furthest from normal range between 00:00 to 24:00 on day of assessment.

labs_coag

descriptive

Coagulation profile

[labs_dailydata]=’1’

Coagulation

This refers to results from coagulation profile

Indicate ‘Yes’ to enter coagulation profile results

1

1

1

1

1

1

1

daily

LABORATORY RESULTS: Record the value furthest from normal range between 00:00 to 24:00 on day of assessment.

labs_prothrombin

number

Prothrombin Time (PT) (s)

number

0

100

[labs_dailydata]=’1’

Coagulation

Refers to the time it takes for blood plasma to clot. It evaluates the extrinsic and common pathways of blood clotting.

Write the PT (seconds).

SNOMED

396451008, Prothrombin time (procedure)

C0033707, Prothrombin time (procedure)

clinical_features

1

1

1

1

1

daily

LABORATORY RESULTS: Record the value furthest from normal range between 00:00 to 24:00 on day of assessment.

labs_aptt

number

Activated Partial Thromboplastin Time (APTT) (s)

number

0

300

[labs_dailydata]=’1’

Coagulation

Refers to the time it takes for clotting to occur when activating reagents are added to a plasma specimen. It evaluates the intrinsic and common pathways of blood clotting.

Write the APTT (sec).

SNOMED

42525009, Partial thromboplastin time, activated (procedure)

C1318441, Activated partial thromboplastin time result

clinical_features

1

1

1

1

1

1

daily

LABORATORY RESULTS: Record the value furthest from normal range between 00:00 to 24:00 on day of assessment.

labs_aptr

number

Activated Partial Thromboplastin Time Ratio (APTR)

number

0

10

[labs_dailydata]=’1’

Coagulation

Refers to the activated partial thromboplastin ratio which is calculated by dividing the patient’s aPTT result by the mean normal aPTT value for the laboratory. The result is a ratio and therefore has no units.

Write the APTR.

SNOMED

391085004, Activated partial thromboplastin time ratio (procedure)

C1272061, Activated partial thromboplastin time ratio

clinical_features

1

1

1

1

1

daily

LABORATORY RESULTS: Record the value furthest from normal range between 00:00 to 24:00 on day of assessment.

labs_tqinr

number

International Normalized Ratio (INR)

number

0

15

[labs_dailydata]=’1’

Coagulation

Refers to international normalised ratio (INR), which is used to standardize prothrombin time (PT) results and is derived from the ratio of a patient’s PT to a control PT, adjusted for the sensitivity of the thromboplastin reagent. The result is a ratio and therefore has no units.

Write the serum INR.

SNOMED

165581004, International normalized ratio (observable entity)

C0525032, International Normalized Ratio

clinical_features

1

1

1

1

1

1

1

1

daily

LABORATORY RESULTS: Record the value furthest from normal range between 00:00 to 24:00 on day of assessment.

labs_fibrinogen

number

Fibrinogen

number

0

1500

[labs_dailydata]=’1’

Coagulation

Fibrinogen is a fibrillar protein present in blood plasma; it converts to fibrin during the process of blood clot formation.

Write the serum Fibrinogen.

clinical_features

1

1

1

1

1

1

daily

LABORATORY RESULTS: Record the value furthest from normal range between 00:00 to 24:00 on day of assessment.

labs_fibrinogen_units

radio

Fibrinogen (select units)

1, g/L | 2, mg/dL

units

[labs_dailydata]=’1’

Coagulation

clinical_features

1

1

1

1

1

daily

LABORATORY RESULTS: Record the value furthest from normal range between 00:00 to 24:00 on day of assessment.

labs_fibrinogen_gl

number

Fibrinogen (g/L)

number

0

15

[labs_dailydata]=’1’

Coagulation

Fibrinogen is a fibrillar protein present in blood plasma; it converts to fibrin during the process of blood clot formation.

Write the serum Fibrinogen (g/L).

SNOMED

250346004, Fibrinogen measurement (procedure)

C0337428, Fibrinogen measurement

clinical_features

1

1

1

1

1

daily

LABORATORY RESULTS: Record the value furthest from normal range between 00:00 to 24:00 on day of assessment.

labs_fibrinogen_mgdl

number

Fibrinogen (mg/dL)

number

0

1500

[labs_dailydata]=’1’

Coagulation

Fibrinogen is a fibrillar protein present in blood plasma; it converts to fibrin during the process of blood clot formation.

Write the serum Fibrinogen (mg/dL).

SNOMED

250346004, Fibrinogen measurement (procedure)

C0337428, Fibrinogen measurement

clinical_features

1

1

1

1

1

daily

LABORATORY RESULTS: Record the value furthest from normal range between 00:00 to 24:00 on day of assessment.

labs_ddimer

number

D-Dimer

number

0

67000

[labs_dailydata]=’1’

Coagulation

D-Dimer is a measure for the concentration of fibrin degradation products (FDPs) in a sample. FDPs are protein fragments produced by the enzymatic action of plasmin on fibrinogen and fibrin) and are an aid in detecting the presence and degree of intravascular coagulation and fibrinolysis (the dissolution of the fibrin in a blood clot) and in monitoring therapy for disseminated intravascular coagulation (nonlocalized clotting in the blood vessels).

Write the serum D-dimer.

clinical_features

1

1

1

1

1

1

daily

LABORATORY RESULTS: Record the value furthest from normal range between 00:00 to 24:00 on day of assessment.

labs_ddimer_units

radio

D-Dimer (select units)

1, µg/L | 2, mg/L

units

[labs_dailydata]=’1’

Coagulation

clinical_features

1

1

1

1

1

daily

LABORATORY RESULTS: Record the value furthest from normal range between 00:00 to 24:00 on day of assessment.

labs_ddimer_mgl

number

D-Dimer (mg/L)

number

0

67

[labs_dailydata]=’1’

Coagulation

D-Dimer is a measure for the concentration of fibrin degradation products (FDPs) in a sample. FDPs are protein fragments produced by the enzymatic action of plasmin on fibrinogen and fibrin) and are an aid in detecting the presence and degree of intravascular coagulation and fibrinolysis (the dissolution of the fibrin in a blood clot) and in monitoring therapy for disseminated intravascular coagulation (nonlocalized clotting in the blood vessels).

Write the serum D-dimer (mg/L)

SNOMED

70648006, D-dimer assay (procedure)

C0200462, D-dimer assay

clinical_features

1

1

1

1

1

daily

LABORATORY RESULTS: Record the value furthest from normal range between 00:00 to 24:00 on day of assessment.

labs_ddimer_ugl

number

D-Dimer (µg/L)

number

0

67000

[labs_dailydata]=’1’

Coagulation

D-Dimer is a measure for the concentration of fibrin degradation products (FDPs) in a sample. FDPs are protein fragments produced by the enzymatic action of plasmin on fibrinogen and fibrin) and are an aid in detecting the presence and degree of intravascular coagulation and fibrinolysis (the dissolution of the fibrin in a blood clot) and in monitoring therapy for disseminated intravascular coagulation (nonlocalized clotting in the blood vessels).

Write the serum D-dimer (ug/L)

SNOMED

70648006, D-dimer assay (procedure)

C0200462, D-dimer assay

clinical_features

1

1

1

1

1

daily

LABORATORY RESULTS: Record the value furthest from normal range between 00:00 to 24:00 on day of assessment.

labs_liver

descriptive

Liver profile

[labs_dailydata]=’1’

Liver profile

This refers to results from liver profile

Indicate ‘Yes’ to enter liver profile testing results

1

1

1

1

1

1

1

1

daily

LABORATORY RESULTS: Record the value furthest from normal range between 00:00 to 24:00 on day of assessment.

labs_bilirubin

number

Total bilirubin

number

0

750

[labs_dailydata]=’1’

Liver profile

This refers to a measurement of the total concentration of bilirubin in blood.

Write the Bilirubin.

clinical_features

1

1

1

1

1

1

1

1

1

1

1

daily

LABORATORY RESULTS: Record the value furthest from normal range between 00:00 to 24:00 on day of assessment.

labs_bilirubin_units

radio

Total bilirubin (select units)

1, µmol/L | 2, mg/dL

units

[labs_dailydata]=’1’

Liver profile

clinical_features

1

1

1

1

1

1

1

1

1

1

daily

LABORATORY RESULTS: Record the value furthest from normal range between 00:00 to 24:00 on day of assessment.

labs_bilirubin_umoll

number

Total bilirubin (µmol/L)

number

0

750

[labs_dailydata]=’1’

Liver profile

This refers to a measurement of the total concentration of bilirubin in blood.

Write the Bilirubin (umol/L).

SNOMED

359986008, Bilirubin, total measurement (procedure)

C0201913, Bilirubin, total measurement

clinical_features

1

1

1

1

1

1

1

1

1

daily

LABORATORY RESULTS: Record the value furthest from normal range between 00:00 to 24:00 on day of assessment.

labs_bilirubin_mgdl

number

Total bilirubin (mg/dL)

number

0

43.9

[labs_dailydata]=’1’

Liver profile

This refers to a measurement of the total concentration of bilirubin in blood.

Write the Bilirubin (mg/dL).

SNOMED

359986008, Bilirubin, total measurement (procedure)

C0201913, Bilirubin, total measurement

clinical_features

1

1

1

1

1

1

1

1

1

daily

LABORATORY RESULTS: Record the value furthest from normal range between 00:00 to 24:00 on day of assessment.

labs_altsgpt

number

Alanine aminotransferase (ALT) / SGPT (U/L)

number

0

20000

[labs_dailydata]=’1’

Liver profile

Alanine aminotransferase (ALT), also referred to as serum glutamic-pyruvic transaminase (SGPT), level in blood.

Write the ALT or SGPT (U/L).

SNOMED

34608000, Alanine aminotransferase measurement (procedure)

C0201836, Alanine aminotransferase measurement

clinical_features

1

1

1

1

1

1

1

1

1

1

daily

LABORATORY RESULTS: Record the value furthest from normal range between 00:00 to 24:00 on day of assessment.

labs_astsgot

number

Aspartate aminotransferase (AST) / SGOT (U/L)

number

0

20000

[labs_dailydata]=’1’

Liver profile

Aspartate aminotransferase (AST), also referred to serum glutamic-oxaloacetic transaminase (SGOT)m level in blood.

Write the AST or SGOT (U/L).

SNOMED

45896001, Aspartate aminotransferase measurement (procedure)

C0201899, Aspartate aminotransferase measurement

clinical_features

1

1

1

1

1

1

1

1

1

1

daily

LABORATORY RESULTS: Record the value furthest from normal range between 00:00 to 24:00 on day of assessment.

labs_alp

number

Alkaline phosphatase (ALP) / (IU/L)

number

0

5000

[labs_dailydata]=’1’

Liver profile

Alkaline phosphatase (ALP) level in blood.

Write the ALP (IU/L).

SNOMED

365771003, Finding of alkaline phosphatase level (finding)

C0201850, Alkaline phosphatase measurement

clinical_features

1

1

1

1

1

1

daily

LABORATORY RESULTS: Record the value furthest from normal range between 00:00 to 24:00 on day of assessment.

labs_ggt

number

Gamma Glutamyl Transferase (GGT) (U/L)

number

0

1220

[labs_dailydata]=’1’

Liver profile

Gamma Glutamyl Transferase or GGT level in blood.

Write the GGT (U/L).

SNOMED

69480007, Gamma glutamyl transferase measurement (procedure)

C0202035, Gamma glutamyl transferase measurement

clinical_features

1

1

1

1

1

1

1

1

daily

LABORATORY RESULTS: Record the value furthest from normal range between 00:00 to 24:00 on day of assessment.

labs_albumin

number

Albumin

number

0

80

[labs_dailydata]=’1’

Liver profile

This refers to the measurement of albumin present in serum.

Write the serum albumin.

clinical_features

1

1

1

1

1

1

1

daily

LABORATORY RESULTS: Record the value furthest from normal range between 00:00 to 24:00 on day of assessment.

labs_albumin_units

radio

Albumin (select units)

1, g/L | 2, mmol/L

units

[labs_dailydata]=’1’

Liver profile

clinical_features

1

1

1

1

1

1

1

daily

LABORATORY RESULTS: Record the value furthest from normal range between 00:00 to 24:00 on day of assessment.

labs_albumin_gl

number

Albumin (g/L)

number

0

80

[labs_dailydata]=’1’

Liver profile

This refers to the measurement of albumin present in serum.

Write the serum albumin (g/L).

SNOMED

104485008, Albumin measurement, serum (procedure)

C0523465, Serum albumin measurement

clinical_features

1

1

1

1

1

daily

LABORATORY RESULTS: Record the value furthest from normal range between 00:00 to 24:00 on day of assessment.

labs_albumin_mmoll

number

Albumin (mmol/L)

number

0

1.2

[labs_dailydata]=’1’

Liver profile

This refers to the measurement of albumin present in serum.

Write the serum albumin (mmol/L).

SNOMED

104485008, Albumin measurement, serum (procedure)

C0523465, Serum albumin measurement

clinical_features

1

1

1

1

1

daily

LABORATORY RESULTS: Record the value furthest from normal range between 00:00 to 24:00 on day of assessment.

labs_bloodglucose

descriptive

Blood glucose

[labs_dailydata]=’1’

Liver profile

This refers to blood glucose related laboratory testing.

1

1

1

1

1

daily

LABORATORY RESULTS: Record the value furthest from normal range between 00:00 to 24:00 on day of assessment.

labs_glucose

number

Random blood glucose

number

0

1801

[labs_dailydata]=’1’

Blood glucose

This refers to the measurement of blood sugar (glucose) levels at any given time, regardless of time of last meal.

Write the random blood glucose. If there are multiple, report the measure furthest from the normal physiological or laboratory range between 00:00 and 24:00 hours on day of assessment.

clinical_features

1

1

1

1

1

1

1

daily

LABORATORY RESULTS: Record the value furthest from normal range between 00:00 to 24:00 on day of assessment.

labs_glucose_units

radio

Random blood glucose (select units)

1, mmol/L | 2, mg/dL | 3, g/L

units

[labs_dailydata]=’1’

Blood glucose

clinical_features

1

1

1

1

1

1

1

daily

LABORATORY RESULTS: Record the value furthest from normal range between 00:00 to 24:00 on day of assessment.

labs_glucose_mmoll

number

Random blood glucose (mmol/L)

number

0

100

[labs_dailydata]=’1’

Blood glucose

This refers to the measurement of blood sugar (glucose) levels at any given time, regardless of time of last meal, in mmol/L.

Write the random blood glucose (mmol/L). If there are multiple, report the measure furthest from the normal physiological or laboratory range between 00:00 and 24:00 hours on day of assessment.

SNOMED

271061004, Random blood glucose measurement (procedure)

C0428567, Random blood glucose measurement

clinical_features

1

1

1

1

1

daily

LABORATORY RESULTS: Record the value furthest from normal range between 00:00 to 24:00 on day of assessment.

labs_glucose_mgdl

number

Random blood glucose (mg/dL)

number

0

1801

[labs_dailydata]=’1’

Blood glucose

This refers to the measurement of blood sugar (glucose) levels at any given time, regardless of time of last meal, in mg/dL.

Write the random blood glucose (mg/dL). If there are multiple, report the measure furthest from the normal physiological or laboratory range between 00:00 and 24:00 hours on day of assessment.

SNOMED

271061004, Random blood glucose measurement (procedure)

C0428567, Random blood glucose measurement

clinical_features

1

1

1

1

1

daily

LABORATORY RESULTS: Record the value furthest from normal range between 00:00 to 24:00 on day of assessment.

labs_glucose_gl

number

Random blood glucose (g/L)

number

0

18.01

[labs_dailydata]=’1’

Blood glucose

This refers to the measurement of blood sugar (glucose) levels at any given time, regardless of time of last meal, in g/L.

Write the random blood glucose (g/L). If there are multiple, report the measure furthest from the normal physiological or laboratory range between 00:00 and 24:00 hours on day of assessment.

SNOMED

271061004, Random blood glucose measurement (procedure)

C0428567, Random blood glucose measurement

clinical_features

1

1

1

1

1

daily

LABORATORY RESULTS: Record the value furthest from normal range between 00:00 to 24:00 on day of assessment.

labs_hba1c

number

HbA1C (%)

number

0

100

[labs_dailydata]=’1’

Blood glucose

Haemoglobin A1C (HbA1C) is a blood test that measures average blood glucose level over the three months preceding the test result, expressed in %.

Write the HbA1C result (%).

SNOMED

43396009, Hemoglobin A1c measurement (procedure)

C0474680, Hemoglobin A1c measurement

clinical_features

1

1

1

1

daily

LABORATORY RESULTS: Record the value furthest from normal range between 00:00 to 24:00 on day of assessment.

labs_renal

descriptive

Renal and electrolyte profile

[labs_dailydata]=’1’

Renal profile

This refers to results from renal profile

Indicate ‘Yes’ to enter renal profile testing results

1

1

1

1

1

1

1

1

daily

LABORATORY RESULTS: Record the value furthest from normal range between 00:00 to 24:00 on day of assessment.

labs_ureanitro

number

Blood Urea Nitrogen (BUN)

number

0

126

[labs_dailydata]=’1’

Renal profile

This refers to blood urea nitrogen (BUN) also called blood urea.

Write the urea/BUN.

clinical_features

1

1

1

1

1

1

1

1

1

daily

LABORATORY RESULTS: Record the value furthest from normal range between 00:00 to 24:00 on day of assessment.

labs_ureanitro_units

radio

Blood Urea Nitrogen (BUN) (select units)

1, mg/dL | 2, mmol/L

units

[labs_dailydata]=’1’

Renal profile

clinical_features

1

1

1

1

1

1

1

1

daily

LABORATORY RESULTS: Record the value furthest from normal range between 00:00 to 24:00 on day of assessment.

labs_ureanitro_mmoll

number

Blood Urea Nitrogen (BUN) (mmol/L)

number

0

45

[labs_dailydata]=’1’

Renal profile

This refers to blood urea nitrogen (BUN) also called blood urea.

Write the urea/BUN (mmol/L).

SNOMED

105011006, Blood urea nitrogen measurement (procedure)

C0005845, Blood urea nitrogen measurement

clinical_features

1

1

1

1

1

1

1

daily

LABORATORY RESULTS: Record the value furthest from normal range between 00:00 to 24:00 on day of assessment.

labs_ureanitro_mgdl

number

Blood Urea Nitrogen (BUN) (mg/dL)

number

0

126

[labs_dailydata]=’1’

Renal profile

This refers to blood urea nitrogen (BUN) also called blood urea.

Write the Urea/BUN (mg/dL).

SNOMED

105011006, Blood urea nitrogen measurement (procedure)

C0005845, Blood urea nitrogen measurement

clinical_features

1

1

1

1

1

1

1

daily

LABORATORY RESULTS: Record the value furthest from normal range between 00:00 to 24:00 on day of assessment.

labs_creatinine

number

Creatinine

number

0

4421

[labs_dailydata]=’1’

Renal profile

This refers to creatinine level in blood.

Write the serum creatinine

clinical_features

1

1

1

1

1

1

1

1

1

1

1

1

daily

LABORATORY RESULTS: Record the value furthest from normal range between 00:00 to 24:00 on day of assessment.

labs_creatinine_units

radio

Creatinine (select units)

1, µmol/L | 2, mg/dL

units

[labs_dailydata]=’1’

Renal profile

clinical_features

1

1

1

1

1

1

1

1

1

1

1

daily

LABORATORY RESULTS: Record the value furthest from normal range between 00:00 to 24:00 on day of assessment.

labs_creatinine_umoll

number

Creatinine (µmol/L)

number

0

4421

[labs_dailydata]=’1’

Renal profile

This refers to creatinine level in blood.

Write the serum creatinine (umol/L).

SNOMED

365756002, Finding of creatinine level (finding)

C0201975, Creatinine measurement

clinical_features

1

1

1

1

1

1

1

1

1

1

daily

LABORATORY RESULTS: Record the value furthest from normal range between 00:00 to 24:00 on day of assessment.

labs_creatinine_mgdl

number

Creatinine (mg/dL)

number

0

50

[labs_dailydata]=’1’

Renal profile

This refers to creatinine level in blood.

Write the serum Creatinine (mg/dL).

SNOMED

365756002, Finding of creatinine level (finding)

C0201975, Creatinine measurement

clinical_features

1

1

1

1

1

1

1

1

1

1

daily

LABORATORY RESULTS: Record the value furthest from normal range between 00:00 to 24:00 on day of assessment.

labs_sodium

number

Sodium (mmol/L or mEq/L)

number

0

300

[labs_dailydata]=’1’

Renal profile

This refers to the serum sodium (Na) level in blood.

Write the serum sodium (mmol/L).

SNOMED

104934005, Sodium measurement, serum (procedure)

C0523891, Serum sodium measurement

clinical_features

1

1

1

1

1

1

1

1

daily

LABORATORY RESULTS: Record the value furthest from normal range between 00:00 to 24:00 on day of assessment.

labs_potassium

number

Potassium (mmol/L or mEq/L)

number

0

10

[labs_dailydata]=’1’

Renal profile

This refers to the serum potassium (K) level in blood.

Write the serum potassium (mmol/L).

SNOMED

271236005, Serum potassium measurement (procedure)

C0302353, Serum potassium measurement

clinical_features

1

1

1

1

1

1

1

1

daily

LABORATORY RESULTS: Record the value furthest from normal range between 00:00 to 24:00 on day of assessment.

labs_creatineki

number

Creatine kinase (U/L)

number

0

10000

[labs_dailydata]=’1’

Renal profile

Creatine kinase or CPK (creatine phosphokinase) refers to the creatinine kinase level in blood.

Write the creatine kinase (U/L).

SNOMED

398137007, Finding of creatine kinase level (finding)

C0201973, Creatine kinase measurement

clinical_features

1

1

1

1

1

1

daily

LABORATORY RESULTS: Record the value furthest from normal range between 00:00 to 24:00 on day of assessment.

labs_ldh

number

Lactate dehydrogenase (LDH) (U/L)

number

0

14000

[labs_dailydata]=’1’

Renal profile

Lactate dehydrogenase or LDH refers to the LDH level in blood.

Write the LDH (U/L).

SNOMED

11274001, Lactate dehydrogenase measurement (procedure)

C0202113, Lactate dehydrogenase measurement

clinical_features

1

1

1

1

1

1

daily

LABORATORY RESULTS: Record the value furthest from normal range between 00:00 to 24:00 on day of assessment.

labs_glomerular

number

Estimated glomerular filtration rate (eGFR) (mL/min/1.73m^2)

number

0

180

[labs_dailydata]=’1’

Renal profile

This refers to the estimated GFR (eGFR), estimated by laboratory calculation.

Write the estimated GFR (mL/min/1.73m^2)

SNOMED

80274001, Glomerular filtration rate (observable entity)

C3811844, Estimated Glomerular Filtration Rate

clinical_features

1

1

daily

LABORATORY RESULTS: Record the value furthest from normal range between 00:00 to 24:00 on day of assessment.

labs_calcium

number

Calcium

number

0

20

[labs_dailydata]=’1’

Renal profile

This refers to serum calcium (Ca) level in blood.

Write the serum calcium.

clinical_features

1

1

daily

LABORATORY RESULTS: Record the value furthest from normal range between 00:00 to 24:00 on day of assessment.

labs_calcium_units

radio

Calcium (select units)

1, mmol/L | 2, mEq/L | 3, mg/dL

units

[labs_dailydata]=’1’

Renal profile

clinical_features

1

1

daily

LABORATORY RESULTS: Record the value furthest from normal range between 00:00 to 24:00 on day of assessment.

labs_calcium_mmoll

number

Calcium (mmol/L)

number

0

5

[labs_dailydata]=’1’

Renal profile

This refers to serum calcium (Ca) level in blood.

Write the serum calcium (mmol/L).

SNOMED

271240001, Serum calcium measurement (procedure)

C0036785, Serum Calcium Level

clinical_features

1

1

daily

LABORATORY RESULTS: Record the value furthest from normal range between 00:00 to 24:00 on day of assessment.

labs_calcium_meql

number

Calcium (mEq/L)

number

0

10

[labs_dailydata]=’1’

Renal profile

This refers to serum calcium (Ca) level in blood.

Write the serum calcium (mEq/L).

SNOMED

271240001, Serum calcium measurement (procedure)

C0036785, Serum Calcium Level

clinical_features

1

1

daily

LABORATORY RESULTS: Record the value furthest from normal range between 00:00 to 24:00 on day of assessment.

labs_calcium_mgdl

number

Calcium (mg/dL)

number

0

20

[labs_dailydata]=’1’

Renal profile

This refers to serum calcium (Ca) level in blood.

Write the serum calcium (mg/dL).

SNOMED

271240001, Serum calcium measurement (procedure)

C0036785, Serum Calcium Level

clinical_features

1

1

daily

LABORATORY RESULTS: Record the value furthest from normal range between 00:00 to 24:00 on day of assessment.

labs_chlor

number

Chloride

number

0

567

[labs_dailydata]=’1’

Renal profile

clinical_features

1

1

daily

LABORATORY RESULTS: Record the value furthest from normal range between 00:00 to 24:00 on day of assessment.

labs_chlor_units

radio

Chloride (select units)

1, mmol/L | 2, mEq/L

units

[labs_dailydata]=’1’

Renal profile

clinical_features

1

1

daily

LABORATORY RESULTS: Record the value furthest from normal range between 00:00 to 24:00 on day of assessment.

labs_chlor_mmoll

number

Chloride (mmol/L)

number

0

160

[labs_dailydata]=’1’

Renal profile

clinical_features

1

1

daily

LABORATORY RESULTS: Record the value furthest from normal range between 00:00 to 24:00 on day of assessment.

labs_chlor_mgdl

number

Chloride (mEq/L)

number

0

567

[labs_dailydata]=’1’

Renal profile

SNOMED

clinical_features

1

1

daily

LABORATORY RESULTS: Record the value furthest from normal range between 00:00 to 24:00 on day of assessment.

labs_magn

number

Magnesium

number

0

12.2

[labs_dailydata]=’1’

Renal profile

clinical_features

1

1

daily

LABORATORY RESULTS: Record the value furthest from normal range between 00:00 to 24:00 on day of assessment.

labs_magn_units

radio

Magnesium (select units)

1, mmol/L | 2, mg/dL

units

[labs_dailydata]=’1’

Renal profile

clinical_features

1

1

daily

LABORATORY RESULTS: Record the value furthest from normal range between 00:00 to 24:00 on day of assessment.

labs_magn_mmoll

number

Magnesium (mmol/L)

number

0

5

[labs_dailydata]=’1’

Renal profile

clinical_features

1

1

daily

LABORATORY RESULTS: Record the value furthest from normal range between 00:00 to 24:00 on day of assessment.

labs_magn_mgdl

number

Magnesium (mg/dL)

number

0

12.2

[labs_dailydata]=’1’

Renal profile

SNOMED

clinical_features

1

1

daily

LABORATORY RESULTS: Record the value furthest from normal range between 00:00 to 24:00 on day of assessment.

labs_inflammatory

descriptive

Inflammatory markers

[labs_dailydata]=’1’

Inflammatory markers

This refers to results from inflammatory marker testing

Indicate ‘Yes’ to enter inflammatory marker testing results

1

1

1

1

1

1

1

daily

LABORATORY RESULTS: Record the value furthest from normal range between 00:00 to 24:00 on day of assessment.

labs_procalcito

number

Procalcitonin

number

0

[labs_dailydata]=’1’

Inflammatory markers

Procalcitonin or PCT refers to serum procalcitonin.

Write the Procalcitonin.

clinical_features

1

1

1

1

1

daily

LABORATORY RESULTS: Record the value furthest from normal range between 00:00 to 24:00 on day of assessment.

labs_procalcito_units

radio

Procalcitonin (select units)

1, ng/mL | 2, µg/L

units

[labs_dailydata]=’1’

Inflammatory markers

clinical_features

1

1

1

1

1

daily

LABORATORY RESULTS: Record the value furthest from normal range between 00:00 to 24:00 on day of assessment.

labs_procalcito_ngml

number

Procalcitonin (ng/mL)

number

0

20

[labs_dailydata]=’1’

Inflammatory markers

Procalcitonin or PCT refers to serum procalcitonin.

Write the Procalcitonin (ng/mL).

SNOMED

418752001, Procalcitonin (substance)

C1535922, Procalcitonin measurement

clinical_features

1

1

1

daily

LABORATORY RESULTS: Record the value furthest from normal range between 00:00 to 24:00 on day of assessment.

labs_procalcito_ugl

number

Procalcitonin (µg/L)

number

0

[labs_dailydata]=’1’

Inflammatory markers

Procalcitonin or PCT refers to serum procalcitonin.

Write the Procalcitonin (ng/mL).

SNOMED

418752001, Procalcitonin (substance)

C1535922, Procalcitonin measurement

clinical_features

1

1

1

daily

LABORATORY RESULTS: Record the value furthest from normal range between 00:00 to 24:00 on day of assessment.

labs_crp

number

C-reactive protein / CRP

number

0

[labs_dailydata]=’1’

Inflammatory markers

C-reactive protein or CRP refers to the serum CRP.

Write the CRP.

clinical_features

1

1

1

1

1

1

1

1

1

daily

LABORATORY RESULTS: Record the value furthest from normal range between 00:00 to 24:00 on day of assessment.

labs_crp_units

radio

C-reactive protein / CRP (select units)

1, mg/L | 2, mg/dL

units

[labs_dailydata]=’1’

Inflammatory markers

clinical_features

1

1

1

1

1

1

1

1

daily

LABORATORY RESULTS: Record the value furthest from normal range between 00:00 to 24:00 on day of assessment.

labs_crp_mgl

number

C-reactive protein (CRP) (mg/L)

number

0

[labs_dailydata]=’1’

Inflammatory markers

C-reactive protein or CRP refers to the serum CRP.

Write the CRP (mg/L).

SNOMED

55235003, C-reactive protein measurement (procedure)

C0201657, C-reactive protein measurement

clinical_features

1

1

1

1

1

1

1

daily

LABORATORY RESULTS: Record the value furthest from normal range between 00:00 to 24:00 on day of assessment.

labs_crp_mgdl

number

C-reactive protein (CRP) (mg/dL)

number

0

[labs_dailydata]=’1’

Inflammatory markers

C-reactive protein or CRP refers to the serum CRP.

Write the CRP (mg/dL).

SNOMED

55235003, C-reactive protein measurement (procedure)

C0201657, C-reactive protein measurement

clinical_features

1

1

1

1

1

1

1

daily

LABORATORY RESULTS: Record the value furthest from normal range between 00:00 to 24:00 on day of assessment.

labs_esr

number

Erythrocyte sedimentation rate (ESR) (mm/h)

number

0

200

[labs_dailydata]=’1’

Inflammatory markers

Erythrocyte Sedimentation Rate or ESR.

Write the ESR (mm/h).

SNOMED

416838001, Erythrocyte sedimentation rate measurement (procedure)

C1176468, Erythrocyte sedimentation rate measurement

clinical_features

1

1

1

1

daily

LABORATORY RESULTS: Record the value furthest from normal range between 00:00 to 24:00 on day of assessment.

labs_bloodgas

descriptive

Blood gas testing

[labs_dailydata]=’1’

Blood gas

This refers to results from blood gas analysis

Indicate ‘Yes’ to enter blood gas analysis results

clinical_features

1

1

1

1

1

1

1

daily

LABORATORY RESULTS: Record the value furthest from normal range between 00:00 to 24:00 on day of assessment.

labs_bloodgas_type

radio

Blood gas specimen type

1, Arterial | 2, Capillary | 3, Venous | 99, Unknown

[labs_dailydata]=’1’

Blood gas

This refers to the type of blood specimen from which blood gas analysis was conducted.

Select the signle most appropriate option which represents the type of blood specimen used for blood gas analysis.

clinical_features

daily

LABORATORY RESULTS: Record the value furthest from normal range between 00:00 to 24:00 on day of assessment.

labs_lactate

number

Serum lactate

number

0

[labs_dailydata]=’1’

Blood gas

This refers to the serum lactate level in blood.

Write the serum lactate.

clinical_features

1

1

1

1

1

1

1

daily

LABORATORY RESULTS: Record the value furthest from normal range between 00:00 to 24:00 on day of assessment.

labs_lactate_units

radio

Serum lactate (select units)

1, mmol/L | 2, mg/dL

units

[labs_dailydata]=’1’

Blood gas

clinical_features

1

1

1

1

1

1

daily

LABORATORY RESULTS: Record the value furthest from normal range between 00:00 to 24:00 on day of assessment.

labs_lactate_mmoll

number

Serum lactate (mmol/L)

number

0

[labs_dailydata]=’1’

Blood gas

This refers to the serum lactate level in blood.

Write the serum lactate (mmol/L).

SNOMED

270982000, Serum lactate measurement (procedure)

clinical_features

1

1

1

1

1

1

1

daily

LABORATORY RESULTS: Record the value furthest from normal range between 00:00 to 24:00 on day of assessment.

labs_lactate_mgdl

number

Serum lactate (mg/dL)

number

0

[labs_dailydata]=’1’

Blood gas

This refers to the serum lactate level in blood.

Write the serum Lactate (mg/dL).

SNOMED

270982000, Serum lactate measurement (procedure)

clinical_features

1

1

1

1

1

1

1

daily

LABORATORY RESULTS: Record the value furthest from normal range between 00:00 to 24:00 on day of assessment.

labs_paco2

number

PaCO2

number

1.33

79

[labs_dailydata]=’1’

Blood gas

This refers to the partial pressure of carbon dioxide measured in the arterial blood recorded in mmHg.

Write the PaCO2. If there are multiple, report the measures from the blood gas with the lowest pH (most acidotic) between 00:00 and 24:00 hours on day of assessment.

clinical_features

1

1

1

1

1

daily

LABORATORY RESULTS: Record the value furthest from normal range between 00:00 to 24:00 on day of assessment.

labs_paco2_units

radio

PaCO2 (select units)

1, mmHg | 2, kPa

units

[labs_dailydata]=’1’

Blood gas

clinical_features

1

1

1

1

daily

LABORATORY RESULTS: Record the value furthest from normal range between 00:00 to 24:00 on day of assessment.

labs_paco2_mmhg

number

PaCO2 (mmHg)

number

10

79

[labs_dailydata]=’1’

Blood gas

This refers to the partial pressure of carbon dioxide measured in the arterial blood recorded in mmHg.

Write the PaCO2 (mmHg). If there are multiple, report the measures from the blood gas with the lowest pH (most acidotic) between 00:00 and 24:00 hours on day of assessment.

SNOMED

250564007, Measurement of partial pressure of carbon dioxide in blood (procedure)

C0391839, Carbon dioxide, partial pressure

clinical_features

1

1

1

1

1

daily

LABORATORY RESULTS: Record the value furthest from normal range between 00:00 to 24:00 on day of assessment.

labs_paco2_kpa

number

PaCO2 (kPa)

number

1.33

10.5

[labs_dailydata]=’1’

Blood gas

This refers to the partial pressure of carbon dioxide measured in the arterial blood recorded in kPa.

Write the PaCO2 (kPa). If there are multiple, report the measures from the blood gas with the lowest pH (most acidotic) between 00:00 and 24:00 hours on day of assessment.

SNOMED

250564007, Measurement of partial pressure of carbon dioxide in blood (procedure)

C0391839, Carbon dioxide, partial pressure

clinical_features

1

1

1

1

1

daily

LABORATORY RESULTS: Record the value furthest from normal range between 00:00 to 24:00 on day of assessment.

labs_ph

number

pH

number

0

14

[labs_dailydata]=’1’

Blood gas

The measurement of the pH of plasma of an arterial blood sample.

Write the pH. If there are multiple, report the measure with the lowest pH (most acidotic) between 00:00 and 24:00 hours on day of assessment.

SNOMED

27051004, pH measurement, arterial (procedure) | 9456006, pH measurement, venous (procedure)

C0853363, Blood pH

clinical_features

1

1

1

1

1

daily

LABORATORY RESULTS: Record the value furthest from normal range between 00:00 to 24:00 on day of assessment.

labs_hco3

number

Bicarbonate (HCO3-) (mmol/L or mEq/L)

number

0

50

[labs_dailydata]=’1’

Blood gas

The measurement of the bicarbonate from plasma of a blood sample.

Write the bicarbonate level (mmol/L or mEq/L). If there are multiple, report the measures from the blood gas with the lowest pH (most acidotic) between 00:00 and 24:00 hours on day of assessment.

SNOMED

365722008, Finding of bicarbonate level (finding)

C0428196, Bicarbonate level - finding

clinical_features

1

1

1

1

1

daily

LABORATORY RESULTS: Record the value furthest from normal range between 00:00 to 24:00 on day of assessment.

labs_baseexcess

number

Base Excess (mmol/L)

number

-9

20

[labs_dailydata]=’1’

Blood gas

The measurement of the base excess/deficit of plasma of an arterial blood sample.

Write the Base Excess (mmol/L). If there are multiple, report the measures from the blood gas with the lowest pH (most acidotic) between 00:00 and 24:00 hours on day of assessment.

SNOMED

129907001, Base excess (finding)

C1330956, Base excess (finding)

clinical_features

1

1

1

1

1

daily

LABORATORY RESULTS: Record the value furthest from normal range between 00:00 to 24:00 on day of assessment.

labs_other

descriptive

Other blood testing

[labs_dailydata]=’1’

This refers to results from other tests / analyses, not specified above

Indicate ‘Yes’ to enter results from other tests / analyses, not specified above

1

1

1

1

1

1

1

daily

LABORATORY RESULTS: Record the value furthest from normal range between 00:00 to 24:00 on day of assessment.

labs_cd4

number

CD4 cell count

number

0

2000

[labs_dailydata]=’1’

Other

Defined as laboratory-based CD4 expressing lymphocyte count, expressed in 10^6 cells/L

Write the CD4+ cell count (cells/mm^3 or 10^6 cells/L or cells/µL).

SNOMED

clinical_features

1

1

1

daily

LABORATORY RESULTS: Record the value furthest from normal range between 00:00 to 24:00 on day of assessment.

labs_cd4_units

radio

CD4 cell count (select units)

1, cells/mm^3 | 2, 10^6 cells/L | 3, cells/µL

units

[labs_dailydata]=’1’

Other

SNOMED

clinical_features

1

1

1

daily

LABORATORY RESULTS: Record the value furthest from normal range between 00:00 to 24:00 on day of assessment.

labs_cd4_celmm

number

CD4 cell count (cells/mm3)

number

0

2000

[labs_dailydata]=’1’

Other

Defined as laboratory-based CD4 expressing lymphocyte count, expressed in 10^6 cells/L

Write the CD4+ cell count (cells/mm^3 or 10^6 cells/L or cells/µL).

SNOMED

313660005, Absolute CD4 count procedure (procedure)

C3541261, CD4 Expressing Cell Count

clinical_features

1

1

daily

LABORATORY RESULTS: Record the value furthest from normal range between 00:00 to 24:00 on day of assessment.

labs_cd4_106cell

number

CD4 cell count (10^6 cells/L)

number

0

2000

[labs_dailydata]=’1’

Other

Defined as laboratory-based CD4 expressing lymphocyte count, expressed in 10^6 cells/L

Write the CD4+ cell count (cells/mm^3 or 10^6 cells/L or cells/µL).

SNOMED

313660005, Absolute CD4 count procedure (procedure)

C3541261, CD4 Expressing Cell Count

clinical_features

1

1

daily

LABORATORY RESULTS: Record the value furthest from normal range between 00:00 to 24:00 on day of assessment.

labs_cd4_celul

number

CD4 cell count (cells/µL)

number

0

2000

[labs_dailydata]=’1’

Other

Defined as laboratory-based CD4 expressing lymphocyte count, expressed in 10^6 cells/L

Write the CD4+ cell count (cells/mm^3 or 10^6 cells/L or cells/µL).

SNOMED

313660005, Absolute CD4 count procedure (procedure)

C3541261, CD4 Expressing Cell Count

clinical_features

1

1

daily

LABORATORY RESULTS: Record the value furthest from normal range between 00:00 to 24:00 on day of assessment.

labs_preg

radio

Pregnancy test

1, Positive | 0, Negative | 99, Unknown

[labs_dailydata]=’1’ and [demog_sex]=’2’

Other

This refers to tests to determine whether or not an individual is pregnant. They include either serum- or urine-based tests to determine the presence of human chorionic gonadotropin (hCG).

Indicate the result of pregnancy test.

SNOMED

74036000, Pregnancy detection examination (procedure)

C0032976, Pregnancy Tests

clinical_features

1

1

1

daily

LABORATORY RESULTS: Record the value furthest from normal range between 00:00 to 24:00 on day of assessment.

labs_tropi

number

Troponin I

number

0

1113

[labs_dailydata]=’1’

Other

clinical_features

1

1

1

1

1

1

daily

LABORATORY RESULTS: Record the value furthest from normal range between 00:00 to 24:00 on day of assessment.

labs_tropi_units

radio

Troponin I (select units)

1, ng/L | 2, ng/mL

units

[labs_dailydata]=’1’

Other

clinical_features

1

1

1

1

1

daily

LABORATORY RESULTS: Record the value furthest from normal range between 00:00 to 24:00 on day of assessment.

labs_tropi_ngl

number

Troponin I (ng/L)

number

0

1113

[labs_dailydata]=’1’

Other

Troponin I, cardiac muscle (210 aa, ~24 kDa) is encoded by the human TNNI3 gene. This protein is involved in muscle filament movement in cardiac cells.

Write the Troponin I.

SNOMED

121870001, Troponin I measurement (procedure)

C0920210, Troponin I measurement

clinical_features

1

1

1

1

1

daily

LABORATORY RESULTS: Record the value furthest from normal range between 00:00 to 24:00 on day of assessment.

labs_tropi_ngml

number

Troponin I (ng/mL)

number

0

1.113

[labs_dailydata]=’1’

Other

Troponin I, cardiac muscle (210 aa, ~24 kDa) is encoded by the human TNNI3 gene. This protein is involved in muscle filament movement in cardiac cells.

Write the Troponin I (ng/mL).

SNOMED

121870001, Troponin I measurement (procedure)

C0920210, Troponin I measurement

clinical_features

1

1

1

1

1

daily

LABORATORY RESULTS: Record the value furthest from normal range between 00:00 to 24:00 on day of assessment.

labs_ferritin

number

Ferritin (µg/L or ng/mL)

number

0

50000

[labs_dailydata]=’1’

Other

Ferritin refers to an iron protein complex, containing up to 23% iron, formed by the union of ferric iron with apoferritin; it is found in the intestinal mucosa, spleen, bone marrow, reticulocytes, and liver, and regulates iron storage and transport from the intestinal lumen to plasma.

Write the serum Ferritin (ug/L or ng/mL).

SNOMED

489004, Ferritin measurement (procedure)

C0696113, Serum ferritin measurement

clinical_features

1

1

1

1

daily

LABORATORY RESULTS: Record the value furthest from normal range between 00:00 to 24:00 on day of assessment.

labs_uric

number

Uric acid

number

0.5

1200

[labs_dailydata]=’1’

1

daily

LABORATORY RESULTS: Record the value furthest from normal range between 00:00 to 24:00 on day of assessment.

labs_uric_units

radio

Uric acid (select units)

1, µmol/L | 2, mg/dL

units

[labs_dailydata]=’1’

1

daily

LABORATORY RESULTS: Record the value furthest from normal range between 00:00 to 24:00 on day of assessment.

labs_uric_umoll

number

Uric acid (µmol/L)

number

30

1200

[labs_dailydata]=’1’

1

daily

LABORATORY RESULTS: Record the value furthest from normal range between 00:00 to 24:00 on day of assessment.

labs_uric_mgdl

number

Uric acid (mg/dL)

number

0.5

20

[labs_dailydata]=’1’

1

daily

LABORATORY RESULTS: Record the value furthest from normal range between 00:00 to 24:00 on day of assessment.

labs_il6

number

Interleukin-6 (IL-6) (pg/mL or ng/L)

number

0

2526

[labs_dailydata]=’1’

Other

Refers to a cytokine that stimulates the growth and differentiation of B-lymphocyte and is also a growth factor for hybridomas and plasmacytomas. It is produced by many different cells including T-lymphocytes; monocytes; and fibroblasts.

Write the IL-6 (pg/mL).

SNOMED

22766004, Interleukin-6 assay (procedure)

C0919829, Interleukin 6 Measurement

clinical_features

1

1

1

1

daily

LABORATORY RESULTS: Record the value furthest from normal range between 00:00 to 24:00 on day of assessment.

labs_protein

number

Total protein (TP)

number

0

150

[labs_dailydata]=’1’

Other

This refers to the amount of total protein in blood.

clinical_features

1

1

1

daily

LABORATORY RESULTS: Record the value furthest from normal range between 00:00 to 24:00 on day of assessment.

labs_protein_units

radio

Total protein (TP) (select units)

1, g/L | 2, g/dL

units

[labs_dailydata]=’1’

Other

clinical_features

1

1

1

daily

LABORATORY RESULTS: Record the value furthest from normal range between 00:00 to 24:00 on day of assessment.

labs_protein_gdl

number

Total protein (TP) (g/dL)

number

0

15

[labs_dailydata]=’1’

Other

This refers to the amount of total protein in blood.

Write the total plasma protein.

SNOMED

304383000, Total protein measurement (procedure)

C0555903, Total protein measurement

clinical_features

1

1

1

daily

LABORATORY RESULTS: Record the value furthest from normal range between 00:00 to 24:00 on day of assessment.

labs_protein_gl

number

Total protein (TP) (g/L)

number

0

150

[labs_dailydata]=’1’

Other

This refers to the amount of total protein in blood.

Write the total plasma protein.

SNOMED

304383000, Total protein measurement (procedure)

C0555903, Total protein measurement

clinical_features

1

1

1

daily

LABORATORY RESULTS: Record the value furthest from normal range between 00:00 to 24:00 on day of assessment.

labs_csfdesc

descriptive

Cerebrospinal fluid (CSF) analysis

[labs_dailydata]=’1’

CSF

Refers to the cerebrospinal fluid (CSF) analyses that were performed at the time that the patient stayed in the clinical facility (hospital) and collected on the date of assessment. In general, results that were rejected by the clinical team (e.g. haemolysed blood samples, contaminated microbiology results) should not be reported.

clinical_features

1

1

1

daily

LABORATORY RESULTS: Record the value furthest from normal range between 00:00 to 24:00 on day of assessment.

labs_csf_pres

number

Opening pressure (cm H2O)

number

0

500

[labs_dailydata]=’1’

CSF

Refers to the opening pressure (in cm of water (H2O)) of CSF measured during a lumbar puncture.

Indicate the opening pressure (cm H2O)

SNOMED

86189008, Cerebrospinal fluid pressure (observable entity)

C2026642, cerebrospinal fluid opening pressure

clinical_features

1

1

daily

LABORATORY RESULTS: Record the value furthest from normal range between 00:00 to 24:00 on day of assessment.

labs_csf_app

radio

Appearance

1, Clear / colourless | 2, Turbid / cloudy | 3, Xanthochromic | 4, Blood stained | 99, Unknown | 88, Other

[labs_dailydata]=’1’

CSF

Refers to the macroscopic appearance of the CSF.

Select the single most appropriate option corresponding to the macroscopic appearance of the CSF.

SNOMED

365665000, Finding of cerebrospinal fluid appearance (finding)

C0427834, CSF (cerebrospinal fluid) appearance clear | C0427835, CSF (cerebrospinal fluid) appearance turbid | C0427823, CSF appearance: xanthochromia | C0427822, CSF appearance: blood-stained

clinical_features

1

daily

LABORATORY RESULTS: Record the value furthest from normal range between 00:00 to 24:00 on day of assessment.

labs_csf_appoth

text

Specify other appearance

[labs_dailydata]=’1’

CSF

Refers to the macroscopic appearance of the CSF.

If ‘Other’, indicate the macroscopic appearance of the CSF.

SNOMED

365665000, Finding of cerebrospinal fluid appearance (finding)

C1287288, CSF appearance - finding

clinical_features

1

daily

LABORATORY RESULTS: Record the value furthest from normal range between 00:00 to 24:00 on day of assessment.

labs_csf_mm3

number

CSF total cell count (cells/mm^3)

number

0

100000

[labs_dailydata]=’1’

CSF

Refers to the number of red and white blood cells that are in cerebrospinal fluid (CSF).

Indicate the CSF cell count.

LOINC

19075-1, CSF cellscounted.total

C4063897, total CSF cell count

clinical_features

1

1

daily

LABORATORY RESULTS: Record the value furthest from normal range between 00:00 to 24:00 on day of assessment.

labs_csf_wbc

number

CSF White blood cell count (cells/mm^3)

number

0

100000

[labs_dailydata]=’1’

CSF

Refers to the number of white blood cells (leukocytes) in the CSF.

Indicate the number of white blood cells (leukocytes) in the CSF.

SNOMED

104112007, White blood cell count, automated, cerebrospinal fluid (procedure)

C0855357, cerebrospinal fluid leukocytes (lab test)

clinical_features

1

1

daily

LABORATORY RESULTS: Record the value furthest from normal range between 00:00 to 24:00 on day of assessment.

labs_csf_rbc

number

CSF Red blood cell count (cells/mm^3)

number

0

1000000

[labs_dailydata]=’1’

CSF

Refers to the number of red blood cells (erythrocytes) in the CSF.

Indicate the number of red blood cells (erythrocytes) in the CSF.

SNOMED

104111000, Red blood cell count, automated, cerebrospinal fluid (procedure)

C3888459, CSF red blood cell count

clinical_features

1

1

daily

LABORATORY RESULTS: Record the value furthest from normal range between 00:00 to 24:00 on day of assessment.

labs_csf_glu

number

CSF Glucose (mg/dL)

number

0

1801

[labs_dailydata]=’1’

CSF

Refers to the glucose level in the CSF.

Indicate the glucose level in the CSF.

SNOMED

365815007, Finding of cerebrospinal fluid: glucose level (finding)

C0202040, Glucose measurement, CSF

clinical_features

1

1

daily

LABORATORY RESULTS: Record the value furthest from normal range between 00:00 to 24:00 on day of assessment.

labs_csf_pro

number

CSF Total protein (mg/dL)

number

0

2000

[labs_dailydata]=’1’

CSF

Refers to the protein level in the CSF.

Indicate the protein level in the CSF.

SNOMED

365808004, Finding of cerebrospinal fluid protein level (finding)

C0201943, Measurement of protein in cerebrospinal fluid specimen

clinical_features

1

1

daily

LABORATORY RESULTS: Record the value furthest from normal range between 00:00 to 24:00 on day of assessment.

labs_csf_cul

radio

CSF Culture result

1, Growth| 0, No growth | 99, Unknown

[labs_dailydata]=’1’

CSF

Refers to a positive CSF culture result, in which an organism was grown on culture.

Select the single most appropriate option corresponding to CSF culture result.

SNOMED

104174003, Microbial culture of cerebrospinal fluid (procedure)

C0430403, Cerebrospinal fluid culture (procedure)

clinical_features

1

1

daily

LABORATORY RESULTS: Record the value furthest from normal range between 00:00 to 24:00 on day of assessment.

labs_csf_culres

user_list

Specify the CSF culture result

pathogens_All

[labs_dailydata]=’1’

CSF

Refers to the organism(s) grown on CSF culture.

Indicate the organism(s) detected on CSF culture.

104174003, Microbial culture of cerebrospinal fluid (procedure)

C0430403, Cerebrospinal fluid culture (procedure)

clinical_features

1

1

daily

LABORATORY RESULTS: Record the value furthest from normal range between 00:00 to 24:00 on day of assessment.

labs_csf_other

radio

Other CSF findings

1, Yes | 0, No

[labs_dailydata]=’1’

CSF

Refers to other CSF findings, not listed above.

Indicate ‘Yes’ if there are other CSF findings not listed above.

104174003, Microbial culture of cerebrospinal fluid (procedure)

C0430403, Cerebrospinal fluid culture (procedure)

clinical_features

1

1

daily

LABORATORY RESULTS: Record the value furthest from normal range between 00:00 to 24:00 on day of assessment.

labs_csf_other_spec

text

Please specify other CSF findings

[labs_csf_other]=’1’

CSF

Refers to other CSF findings, not listed above.

If ‘Yes’, specify the CSF findings not listed above.

104174003, Microbial culture of cerebrospinal fluid (procedure)

C0430403, Cerebrospinal fluid culture (procedure)

clinical_features

1

1

daily

IMAGING

imagi_dailydata

radio

Enter Imaging data for this date?

1, Yes | 0, No

This refers only to those imaging or radiological test(s) that were performed at the time that the patient stayed in the clinical facility (hospital) and collected on the date of assessment.

Indicate ‘Yes’, if imaging or radiological test(s) were performed at the time that the patient stayed in the clinical facility (hospital) and collected on the date of assessment.

1

1

1

1

1

1

1

1

daily

IMAGING

imagi_xray

radio

Chest X-ray performed

1, Yes | 0, No | 99, Unknown

[imagi_dailydata]=’1’

This refers to any chest x-ray that was performed at the time the patient stayed in the clinical facility (hospital) and collected on the date of assessment. Chest x-ray refers to radiological visualization of the chest and organs of the thoracic cavity; not restricted to visualization of the lungs, using x-rays.

Indicate ‘Yes’, if any chest x-ray was performed at the time the patient stayed in the clinical facility (hospital) and collected on the date of assessment.

SNOMED

SNOMED

C0039985, Plain chest X-ray

1

1

1

1

1

1

1

1

1

daily

IMAGING

imagi_xray_date

date_dmy

Chest X-ray date

date_dmy

today

[imagi_xray] = ‘1’

This refers to the date when the chest x-ray was performed.

Enter the date when the chest x-ray was performed (use the format DD/MM/YYYY).

1

1

1

daily

IMAGING

imagi_xray_result

radio

Chest X-ray findings associated with this illness.

1, Normal or no acute change | 5, Abnormal or acute change | 99, Unknown

[imagi_xray] = ‘1’

This refers to chest X-ray findings associated with this illness.

Select the single most appropriate option corresponding to the chest X-ray findings associated with this illness.

SNOMED

SNOMED

C0239026, Standard chest X-ray normal | C0436503, Standard chest X-ray abnormal

1

1

1

1

1

1

1

1

1

daily

IMAGING

imagi_xray_newinfilt

radio

New infiltrates present on X-ray

1, Yes, bilateral | 2, Yes, unilateral | 0, No | 99, Unknown

[imagi_xray_result]=’5’

This refers to new pulmonary infiltrates present on the current chest x-ray, not visualised on previous chest radiographs of the patient. Pulmonary infiltrates result when a substance denser than air (e.g., pus, oedema, blood, surfactant, protein, or cells) is present within the lung parenchyma. Bilateral pulmonary infiltrates are present in both lungs. Unilateral pulmonary infiltrates are present in one lung only.

Select the single most appropriate option corresponding to the new pulmonary infiltrates present on the current chest x-ray, not visualised on previous chest radiographs of the patient.

1

1

1

1

1

1

1

1

1

daily

IMAGING

imagi_xray_infiltyp

checkbox

Infiltrates on X-ray consistent with

1, Viral pneumonitis | 2, Bacterial pneumonia |3, Pulmonary oedema| 99, Unknown

[imagi_xray_newinfilt] = ‘1’ or [imagi_xray_newinfilt]=’2’

This refers to the pathological condition with which the pulmonary infiltrates on chest x-ray may be consistent with. Viral pneumonitis characteristically produces bilateral perihilar peribronchial thickening and interstitial infiltrates which, particularly in children, due to their small-calibre airways, can result in areas of atelectasis or air trapping. Bacterial pneumonia characteristically produces focal segmental (i.e. bronchopneumonia) or lobar pulmonary opacities (i.e. lobar pneumonia). Pulmonary oedema may be characterised by cephalisation of upper lobe vessels, interstitial opacities, peribronchovascular cuffing, septal lines (Kerley B lines), airspace opacification (filling of the alveoli with fluid) which can have a perihilar or ‘batwing’ distribution when severe and acute; and pleural effusion.

Select all that apply.

SNOMED

SNOMED

C0032310, Pneumonia, Viral | C0004626, Pneumonia, Bacterial | C0034063, Pulmonary Oedema

1

1

1

1

1

1

1

1

daily

IMAGING

imagi_xray_pleueff

radio

Pleural effusion on X-ray

1, Yes | 0, No | 99, Unknown

[imagi_xray_result]=’5’

This refers to presence of fluid in the pleural cavity resulting from excessive transudation or exudation from the pleural surfaces.

Indicate ‘Yes’, if pleural effusion was visualised on chest x-ray.

SNOMED

SNOMED

C0032227, Pleural effusion (disorder)

1

1

1

1

1

1

1

1

1

daily

IMAGING

imagi_xray_resultpleu

radio

Pleural effusion on X-ray details

1, Unilateral | 2, Bilateral

[imagi_xray_pleueff]=’1’

This refers to the location of the pleural effusion.

Indicate the location of the pleural effusion.

1

1

1

1

1

1

1

daily

IMAGING

imagi_xray_resultpleusite

checkbox

Side(s) where pleural effusion identified

1, Right | 2, Left

[imagi_xray_pleueff]=’1’

This refers to the side where the unilateral pleural effusion is located.

Indicate the side of the pleural effusion.

1

1

daily

IMAGING

imagi_ctchest

radio

CT chest performed

1, Yes | 0, No | 99, Unknown

[imagi_dailydata]=’1’

This refers to computed tomography imaging of the chest.

Indicate ‘Yes’, if any CT chest was performed at the time the patient stayed in the clinical facility (hospital) and collected on the date of assessment.

1

1

1

1

1

daily

IMAGING

imagi_ctchest_result

radio

CT chest findings associated with this illness

1, Normal or no acute change | 5, Abnormal or acute change | 99, Unknown

[imagi_ctchest] = ‘1’

Refers to the findings identified on the CT chest. Pulmonary infiltrates refers to the presence of pulmonary or lung infiltrates and can include alveolar, air space, interstitial, or nodular infiltrates and typically refers to a substance or type of cell that is foreign to the lung, or accumulates in greater than normal quantity within it.

Select the single most appropriate option corresponding to the chest CT findings associated with this illness.

1

1

1

1

daily

IMAGING

imagi_ctchest_infiltra

radio

New infiltrates present on CT

1, Yes, bilateral | 2, Yes, unilateral | 0, No | 99, Unknown

[imagi_ctchest_result]=’5’

This refers to new pulmonary infiltrates present on the current chest CT scan, not visualised on previous chest radiographs of the patient. Pulmonary infiltrates result when a substance denser than air (e.g., pus, oedema, blood, surfactant, protein, or cells) is present within the lung parenchyma. Bilateral pulmonary infiltrates are present in both lungs. Unilateral pulmonary infiltrates are present in one lung only.

Select the single most appropriate option corresponding to the new pulmonary infiltrates present on the current chest CT scan, not visualised on previous chest radiographs of the patient.

1

1

1

1

daily

IMAGING

imagi_ctchest_infiltyp

checkbox

Infiltrates on CT chest consistent with

1, Viral pneumonitis | 2, Bacterial pneumonia |3, Pulmonary oedema| 99, Unknown

[imagi_ctchest_infiltra] = ‘1’ or [imagi_ctchest_infiltra]=’2’

This refers to the pathological condition with which the pulmonary infiltrates on chest x-ray may be consistent with. Viral pneumonitis characteristically produces bilateral perihilar peribronchial thickening and interstitial infiltrates which, particularly in children, due to their small-calibre airways, can result in areas of atelectasis or air trapping. Bacterial pneumonia characteristically produces focal segmental (i.e. bronchopneumonia) or lobar pulmonary opacities (i.e. lobar pneumonia). Pulmonary oedema may be characterised by cephalisation of upper lobe vessels, interstitial opacities, peribronchovascular cuffing, septal lines (Kerley B lines), airspace opacification (filling of the alveoli with fluid) which can have a perihilar or ‘batwing’ distribution when severe and acute; and pleural effusion.

Select all that apply.

SNOMED

SNOMED

C0032310, Pneumonia, Viral | C0004626, Pneumonia, Bacterial | C0034063, Pulmonary Oedema

1

1

1

1

daily

IMAGING

imagi_ctchest_pleueff

radio

Pleural effusion on CT chest

1, Yes | 0, No | 99, Unknown

[imagi_ctchest_result]=’5’

This refers to presence of fluid in the pleural cavity resulting from excessive transudation or exudation from the pleural surfaces.

Indicate ‘Yes’, if pleural effusion was visualised on chest CT scan.

SNOMED

SNOMED

C0032227, Pleural effusion (disorder)

1

1

1

1

1

1

daily

IMAGING

imagi_ctchest_resultpleudet

radio

Pleural effusion on CT chest details

1, Unilateral | 2, Bilateral

[imagi_ctchest_pleueff]=’1’

This refers to the location of the pleural effusion.

Indicate the location of the pleural effusion.

1

1

1

daily

IMAGING

imagi_ctbrain

radio

CT brain performed

1, Yes | 0, No | 99, Unknown

[imagi_dailydata]=’1’

This refers to computed tomography imaging of the brain.

Indicate ‘Yes’, if any Brain CT scan was performed at the time the patient stayed in the clinical facility (hospital) and collected on the date of assessment.

1

1

1

daily

IMAGING

imagi_ctbrain_date

date_dmy

CT brain date

date_dmy

today

[imagi_ctbrain] = ‘1’

This refers to the date of the brain CT scan.

Enter the date when the CT was performed. (Use the format DD/MM/YYYY)

1

daily

IMAGING

imagi_ctbrain_findings

text

CT brain findings

[imagi_ctbrain] = ‘1’

This refers to the key findings of the brain CT scan.

Write the key findings of the Brain CT scan.

1

1

1

daily

IMAGING

imagi_mrib

radio

MRI brain performed

1, Yes | 0, No | 99, Unknown

[imagi_dailydata]=’1’

This refers to magnetic resonance imaging (MRI) of the brain.

Indicate ‘Yes’, if any Brain MRI scan was performed at the time the patient stayed in the clinical facility (hospital) and collected on the date of assessment.

1

1

1

daily

IMAGING

imagi_mrib_date

date_dmy

MRI brain date

date_dmy

today

[imagi_mrib] = ‘1’

This refers to the date of the brain MRI scan.

Enter the date when the MRI was performed. (Use the format DD/MM/YYYY)

1

daily

IMAGING

imagi_mrib_findings

text

MRI brain findings

[imagi_mrib] = ‘1’

This refers to the key findings of the brain MRI scan.

Write the key findings of the Brain MRI scan.

1

1

1

daily

IMAGING

imagi_ultrasound

radio

Ultrasound performed

1, Yes | 0, No | 99, Unknown

[imagi_dailydata]=’1’

This refers to any ultrasound imaging that was performed at the time the patient stayed in the clinical facility (hospital) and collected on the date of assessment.

Indicate ‘Yes’, if ultrasound imaging was performed at the time the patient stayed in the clinical facility (hospital) and collected on the date of assessment.

SNOMED

SNOMED

C0041618, Ultrasonography

1

1

1

1

1

daily

IMAGING

imagi_ultrasound_date

date_dmy

Ultrasound date

date_dmy

today

[imagi_ultrasound] = ‘1’

This refers to the date when the ultrasound imaging was performed.

Enter the date when the ultrasound was performed. (Use the format DD/MM/YYYY)

1

1

daily

IMAGING

imagi_ultrasound_site

radio

Ultrasound region

1, Chest only | 2, Abdomen only | 3, Chest and abdomen | 4, Cranial | 5, Joints | 99, Unknown

[imagi_ultrasound]=’1’

This refers to the region of the body which was assessed using ultrasound imaging.

Indicate the region of the body which was assessed using ultrasound imaging.

SNOMED

SNOMED

C0883613, Ultrasound chest | C0203464, Ultrasonography of abdomen | C4750624, Ultrasonography of chest and abdomen

1

1

1

1

1

daily

IMAGING

imagi_ultrasound_findi

radio

Ultrasound findings associated with this illness

1, Normal or no acute change | 5, Abnormal or acute change | 99, Unknown

[imagi_ultrasound]=’1’

This refers to ultrasound imaging findings associated with this illness.

Select the single most appropriate option corresponding to the ultrasound imaging findings associated with this illness.

SNOMED

SNOMED

C0581117, Ultrasound scan normal | C0581118, Ultrasound scan abnormal

1

1

1

1

1

daily

IMAGING

imagi_ultrasound_asc

radio

Ascites

1, Yes | 0, No | 99, Unknown

[imagi_ultrasound_findi]=’5’

Ascites refers to a pathological increase of fluid in the peritoneal cavity.

Indicate ‘Yes’ If ascites were identified on ultrasound on date of assessment. Indicate ‘No’ if there was no ascites on ultrasound on date of assessment. If the peritoneal cavity was not examined by ultrasound for ascites on date of assessment indicate ‘Unknown’.

SNOMED

SNOMED

C0003962, Ascites

1

1

1

1

daily

IMAGING

imagi_ultrasound_ascsit

radio

Ascites grading

1, Small | 2, Moderate | 3, Severe

[imagi_ultrasound_asc] = ‘1’

Mild/small ascites (grade 1) is detectable only by ultrasonography and typically requires approximately 100mL of fluid (where normal volume is approximately 25-50mL); Moderate ascites (grade 2) implying at least 500-1000mL of peritoneal fluid and detected with physical examination; Severe ascites (grade 3) refers to the manifestation of grossly distended abdomen, may be described as tense ascites.

Select the single most appropriate option corresponding to the grade of ascites detected on ultrasound imaging.

1

1

daily

IMAGING

imagi_ultrasound_consoli

radio

Consolidation

1, Yes | 0, No | 99, Unknown

[imagi_ultrasound_findi]=’5’

This refers to the presence of a radio-opaque area in the lung. The opacification is caused by fluid or solid material within the airways or lung parenchyma.

Indicate ‘Yes’ if consolidation was identified on ultrasound on date of assessment. Indicate ‘No’ if there was no pleural effusion(s) on ultrasound on date of assessment. Indicate ‘Unknown’ if the pleural space was not examined by ultrasound for pleural effusion(s) on date of assessment.

SNOMED

SNOMED

1

1

1

1

daily

IMAGING

imagi_ultrasound_pleff

radio

Pleural effusion

1, Yes | 0, No | 99, Unknown

[imagi_ultrasound_findi]=’5’

Pleural effusion refers to a pathological increase of fluid in the pleural space.

Indicate ‘Yes’ if pleural effusion(s) was identified on ultrasound on date of assessment. Indicate ‘No’ if there was no pleural effusion(s) on ultrasound on date of assessment. Indicate ‘Unknown’ if the pleural space was not examined by ultrasound for pleural effusion(s) on date of assessment.

SNOMED

SNOMED

C0032227, Pleural effusion (disorder)

1

1

1

1

daily

IMAGING

imagi_ultrasound_plefr

number

Pleural effusion right size (cm)

number

0

20

[imagi_ultrasound_pleff] = ‘1’

Refers to the depth of the pleural effusion in centimetres (cm).

Indicate the depth of pleural effusion on the right side in centimetres (cm).

1

1

daily

IMAGING

imagi_ultrasound_plefl

number

Pleural effusion left size (cm)

number

0

20

[imagi_ultrasound_pleff] = ‘1’

Refers to the depth of the pleural effusion in centimetres (cm).

Indicate the depth of pleural effusion on the left side in centimetres (cm).

1

1

daily

IMAGING

imagi_ultrasound_peric

radio

Pericardial effusion

1, Yes | 0, No | 99, Unknown

[imagi_ultrasound_findi]=’5’

Pericardial effusion refers to a pathological increase of fluid in the pericardial space.

If pericardial effusion was identified on ultrasound on date of assessment Indicate ‘Yes’. If there was no pericardial effusion on ultrasound on date of assessment Indicate ‘No’. If the pericardial space was not examined by ultrasound for a pericardial effusion on date of assessment Indicate ‘Unknown’.

SNOMED

SNOMED

1

1

1

1

daily

IMAGING

imagi_ultrasound_perics

number

Pericardial effusion size (cm)

number

0

5

[imagi_ultrasound_peric] = ‘1’

Refers to the depth of the pericardial effusion in centimetres (cm).

Indicate the depth of pericardial effusion on the left side in centimetres (cm).

1

1

daily

IMAGING

imagi_liversize

number

Liver size (cm)

number

0

30

[imagi_ultrasound] = ‘1’

Refers to the craniocaudal length of the liver along the midclavicular line, in centimeters (cm).

Indicate the craniocaudal length of the liver along the midclavicular line, in centimeters (cm).

SNOMED

SNOMED

C0426688, Liver size (observable entity)

1

1

daily

IMAGING

imagi_gallbladder

number

Gallbladder wall (mm)

number

0

20

[imagi_ultrasound] = ‘1’

Refers to the thickness of the gallbladder wall, in millimeters (mm).

Indicate the thickness of the gallbladder wall, in millimeters (mm).

1

1

daily

IMAGING

imagi_ultrasound_unlisted

radio

Other finding(s)

1, Yes | 0, No | 99, Unknown

[imagi_ultrasound] = ‘1’

Refers to other ultrasound findings which are clinically relevant.

Indicate ‘Yes’, if there are other ultrasound imaging findings which are clinically relevant.

1

1

daily

IMAGING

imagi_ultrasound_unlistedoth

text

Specify other findings

[imagi_ultrasound_unlisted] = ‘1’

Refers to other ultrasound imaging findings which are clinically relevant.

If ‘Yes’, specify the other ultrasound imaging findings which are clinically relevant.

1

1

daily

IMAGING

imagi_ecg

radio

Electrocardiogram (ECG)

1, Yes-normal | 2, Yes-abnormal | 0, No | 99, Unknown

[imagi_dailydata]=’1’

Refers to a study that evaluates the effect of a treatment on cardiac electrical activity, as assessed by electrocardiography.

Select the most appropriate options which corresponds to the ECG findings.

SNOMED

164854000, Electrocardiogram normal (finding) | 102594003, Electrocardiogram abnormal (finding)

daily

IMAGING

imagi_ecg_spec

text

ECG summary

[imagi_ecg]=’2’

Refers to a summary of the key ECG findings

If ‘Yes-abnormal’ give a summary of the key ECG findings.

daily

IMAGING

imagi_ecg_date

date_dmy

ECG date

date_dmy

today

[imagi_ecg]=’1’ or [imagi_ecg]=’2’

Refers to the date of the ECG

Enter the date when the ECG was performed.. (Use the format DD/MM/YYYY)

medication

MEDICATION: Record medications administered or prescribed from day of presentation to day of discharge / outcome (one form per medication).

medi_medtype

user_list

Select agents administered while hospitalised or at discharge (one form per medication)

drugs_Type

This refers to all medications administered any time during the patient’s admission in the clinical facility (hospital), including in the emergency department, and prescribed on discharge.

Indicate the type of agent, for all medications administered any time during the patient’s admission in the clinical facility (hospital), including in the emergency department, and prescribed on discharge.

1

1

1

1

1

1

1

1

1

medication

MEDICATION: Record medications administered or prescribed from day of presentation to day of discharge / outcome (one form per medication).

medi_treat

radio

Is this medication treating the disease?

1, Yes | 0, No

This refers to whether the medication is being used to treat the disease caused by the pathogen of interest.

Indicate ‘Yes’ if this medication is being used to treat the disease caused by the pathogen of interest.

1

1

1

1

1

1

1

medication

MEDICATION: Record medications administered or prescribed from day of presentation to day of discharge / outcome (one form per medication).

medi_antiviralagent

user_list

Antiviral

drugs_Antiviral

[medi_medtype] = ‘8’

Refers to any agent(s) prescribed specifically to treat a suspected or confirmed viral infection. Examples of neuraminidase inhibitors include oseltamivir, ribavirin, acyclovir and lopinavir/ritonavir. Topical preparations are not included.

Select the antiviral agent(s) administered any time during the patient’s admission in the clinical facility (hospital), including in the emergency department, and prescribed on discharge.

clinical_features, treatment

1

1

1

1

1

1

1

medication

MEDICATION: Record medications administered or prescribed from day of presentation to day of discharge / outcome (one form per medication).

medi_antibioagent

user_list

Antibiotic

drugs_Antibiotics

[medi_medtype]=’2’

Antibiotics refers to any agent(s) that selectively target bacteria.

Select the antibiotic agent(s) administered any time during the patient’s admission in the clinical facility (hospital), including in the emergency department, and prescribed on discharge.

SNOMED

346325008 |Medicinal product acting as antibacterial agent (product)|

C0279516, Antibacterial

clinical_features, treatment

1

1

1

1

1

1

1

1

medication

MEDICATION: Record medications administered or prescribed from day of presentation to day of discharge / outcome (one form per medication).

medi_topicantibiotgent

radio

Topical antibiotic

1, Penicillins | 2, Cephalosporins | 3, Tetracyclines | 4, Aminoglycosides | 5, Macrolides | 6, Sulfonamides and trimethoprim | 7, Quinolones | 99, Unknown | 88, Other

[medi_medtype]=’16’

Refers to the antibiotic class of topical antibiotic(s) administered during admission and/or prescribed on discharge.

Indicate the class of topical antibiotic(s) administered during admission and/or prescribed on discharge

1

1

medication

MEDICATION: Record medications administered or prescribed from day of presentation to day of discharge / outcome (one form per medication).

medi_corticost

user_list

Corticosteroid

drugs_Steroids

[medi_medtype]=’10’

Corticosteroids (commonly referred to as ‘steroids’) refers to all types of therapeutic corticosteroid, made in the adrenal cortex (the outer part of the adrenal gland). They are also made in the laboratory. Examples include: prednisolone, prednisone, methyl-prednisolone, dexamethasone, hydrocortisone, fluticasone, betametasone. Topical preparations are not included, but inhaled preparations are included.

Select the corticosteroid(s) administered any time during the patient’s admission in the clinical facility (hospital), including in the emergency department, and prescribed on discharge.

SNOMED

788326005 |Product containing adrenal cortex hormone (product)|

CL554601, Therapeutic corticosteroid

clinical_features, treatment

1

1

1

1

1

1

1

1

1

medication

MEDICATION: Record medications administered or prescribed from day of presentation to day of discharge / outcome (one form per medication).

medi_anticoaguagent

user_list

Anticoagulation

drugs_Anticoagulant

[medi_medtype]=’3’

An anticoagulant refers to any agent capable of preventing blood clot formation, or platelet aggregation. This includes agents such as heparin, warfarin, aspirin, clopidogrel, and subcutaneously administered anticoagulants, among many others. Topical preparations are not included.

Select the anticoagulant(s) administered any time during the patient’s admission in the clinical facility (hospital), including in the emergency department, and prescribed on discharge.

SNOMED

81839001 |Medicinal product acting as anticoagulant agent (product)|

C0003280, Anticoagulant agent

1

1

1

1

1

medication

MEDICATION: Record medications administered or prescribed from day of presentation to day of discharge / outcome (one form per medication).

medi_anticoaguagent_ind

radio

Anticoagulation indication

1, Therapeutic (treatment of DVT/PE) | 2, Enhanced prophylaxis for infection with pathogen of interest | 3, Routine inpatient prophylaxis | 99, Unknown

[medi_medtype]=’3’

This refers to the indication of the anticoagulant(s).

Select the single most appropriate option corresponding to the indication of the anticoagulant(s).

1

1

1

1

medication

MEDICATION: Record medications administered or prescribed from day of presentation to day of discharge / outcome (one form per medication).

medi_antifungagent

user_list

Antifungal agent

drugs_Antifungal

[medi_medtype]=’4’

Refers to any agent(s) inhibiting the growth of or killing fungi, prescribed specifically to treat a suspected or confirmed fungal infection.

Select the antifungal agent(s) administered any time during the patient’s admission in the clinical facility (hospital), including in the emergency department, and prescribed on discharge.

1

1

1

1

1

medication

MEDICATION: Record medications administered or prescribed from day of presentation to day of discharge / outcome (one form per medication).

medi_inotropesvasopressor

radio

Inotropes / vasopressor

1, Vasopressin | 2, Phenylephrine | 3, Epinephrine | 4, Norepinephrine | 5, Dopamine | 6, Angiotensin-II | 7, Terlipressin | 88, Other

[medi_medtype] = ‘14’

This refers to continuous use of a vasopressor or inotrope for at least one hour. Agents include norepinephrine, epinephrine, vasopressin, terlipressin and phenylephrine. Commonly used ‘positive’ inotropes include dobutamine, dopamine, milrinone and adrenaline (epinephrine).

Select the vasopressor or inotrope agent administered any time during the patient’s admission in the clinical facility (hospital), including in the emergency department, and prescribed on discharge.

SNOMED

870386000, Vasopressor therapy (procedure) | 1296972008, Inotropic therapy (procedure)

C5396785, Vasopressor therapy | C5880944, Inotropic therapy

clinical_features, treatment

1

1

medication

MEDICATION: Record medications administered or prescribed from day of presentation to day of discharge / outcome (one form per medication).

medi_analgesic

radio

Analgesic agent

1, Paracetamol | 2, NSAIDs | 3, Opiates (Tramadol, Codeine, Morphine) | 4, Ketamine | 99, Unknown | 88, Other

[medi_medtype]=’1’

This refers to any agents that alleviate pain without loss of consciousness. These include opioid, non-opioid and adjuvant analgesic agents.

Indicate the analgesic agent(s) administered any time during the patient’s admission in the clinical facility (hospital), including in the emergency department, and prescribed on discharge.

1

1

1

1

medication

MEDICATION: Record medications administered or prescribed from day of presentation to day of discharge / outcome (one form per medication).

medi_antipruritic

radio

Antipruritic agent

1, Hydrocortisone | 2, Calamine | 3, Antihistamines | 4, Hydroxyzine | 99, Unknown | 88, Other

[medi_medtype]=’7’

This refers to any agent(s) that relieve itching (pruritus).

Select the antipruritic agent(s) administered any time during the patient’s admission in the clinical facility (hospital), including in the emergency department, and prescribed on discharge.

1

1

medication

MEDICATION: Record medications administered or prescribed from day of presentation to day of discharge / outcome (one form per medication).

medi_immunosupp

user_list

Immunosuppressive drugs (non-steroid)

drugs_Immunosuppressants

[medi_medtype]=’13’

This refers to a patient who is known to have taken prescribed medications that are known to have an immunosuppressing effect (excluding steroids/corticosteroids).

Select the single most appropriate option corresponding to the indication of the immunosuppressant(s).

1

medication

MEDICATION: Record medications administered or prescribed from day of presentation to day of discharge / outcome (one form per medication).

medi_ivig

radio

Type of intravenous immunoglobulin

1, Polyclonal immunoglobulin | 2, Specific immunoglobulin | 99, Unknown | 88, Other

[medi_medtype]=’15’

This refer to the type of intravenous immunoglobulin.

Select the single most appropriate option which represents the type of intravenous immunoglobulin administered.

1

medication

MEDICATION: Record medications administered or prescribed from day of presentation to day of discharge / outcome (one form per medication).

medi_ivig_oth

text

Specify other type of intravenous immunoglobulin

[medi_ivig] = ‘88’

If ‘Other’, specify the type of intravenous immunoglobulin.

Specify the type of intravenous immunoglobulin.

1

medication

MEDICATION: Record medications administered or prescribed from day of presentation to day of discharge / outcome (one form per medication).

medi_route

radio

Medication route

1, Oral | 2, Subcutaneous |3, Inhaled |4, IV | 5, Topical | 99, Unknown | 88, Other

[medi_medtype]=’8’ or [medi_medtype]=’10’ or [medi_medtype]=’3’ or [medi_medtype]=’1’ or [medi_medtype]=’7’ or [medi_medtype]=’13’ or [medi_medtype_otherl2]=’8’ or [medi_medtype_otherl2]=’10’ or [medi_medtype_otherl2]=’3’ or [medi_medtype_otherl2]=’1’ or [medi_medtype_otherl2]=’7’ or [medi_medtype_otherl2]=’13’

This refers ot the route of administration of the medication.

Select the single most appropriate option which represents the route of administration of the medication.

1

1

1

1

1

1

1

1

1

medication

MEDICATION: Record medications administered or prescribed from day of presentation to day of discharge / outcome (one form per medication).

medi_route_oth

text

Specify other route

[medi_route]=’88’

This refers ot the route of administration of the medication.

If ‘Other’, indicate the route of administration of the medication.

1

1

1

1

1

1

1

1

medication

MEDICATION: Record medications administered or prescribed from day of presentation to day of discharge / outcome (one form per medication).

medi_localanest

radio

Local anaesthetic

1, Lidocaine | 2, Bupivacaine | 3, Ropivacaine | 88, Other

[medi_medtype] =’17’

1

medication

MEDICATION: Record medications administered or prescribed from day of presentation to day of discharge / outcome (one form per medication).

medi_localanest_other

text

Specify other Local anaesthetic

[medi_localanest]=’88’

1

medication

MEDICATION: Record medications administered or prescribed from day of presentation to day of discharge / outcome (one form per medication).

medi_medstartdate

date_dmy

Date medication started / first dose

date_dmy

today

[medi_treat]=’1’

This refers to the date the medication was started / first dose was administered.

Enter the date when the medication was started / first dose was given. (Use the format DD/MM/YYYY)

C5236155, Date of First Dose

treatment

1

1

1

1

1

1

1

1

1

medication

MEDICATION: Record medications administered or prescribed from day of presentation to day of discharge / outcome (one form per medication).

medi_medongoing

radio

Therapy ongoing?

1, Yes | 2, No | 99, Unknown

[medi_treat]=’1’

This refers to ongoing therapy with medication being used to treat the disease caused by the pathogen of interest.

Indicate if there is ongoing therapy with medication being used to treat the disease caused by the pathogen of interest.

1

medication

MEDICATION: Record medications administered or prescribed from day of presentation to day of discharge / outcome (one form per medication).

medi_medenddate

date_dmy

Date medication stopped / last dose

date_dmy

today

[medi_treat]=’1’

This refers to the date the medication was stopped / last dose was administered.

Enter the date when the medication was ended / last dose was given. (Use the format DD/MM/YYYY)

C1762893, Date last dose

treatment

1

1

1

1

1

1

1

1

1

medication

MEDICATION: Record medications administered or prescribed from day of presentation to day of discharge / outcome (one form per medication).

medi_numdays

number

Total number of days treatment given

number

0

[medi_treat]=’1’

This refers to the total number of days for which a dose was received or instructed to take on discharge prescription.

Enter the total number of days for which a dose was received or instructed to take on discharge prescription.

C5786895, Treatment Duration in Days

treatment

1

1

1

1

1

1

1

1

1

medication

MEDICATION: Record medications administered or prescribed from day of presentation to day of discharge / outcome (one form per medication).

medi_stopreason

radio

Reasons for treatment stopping

1, Improvements | 2, Deterioration | 3, Death | 4, Other adverse events | 99, Unknown | 88, Other

[medi_medongoing] = ‘2’

This refers to the reason for stopping treatment.

Select the single most appropriate option corresponding to the reason for stopping treatment.

medication

MEDICATION: Record medications administered or prescribed from day of presentation to day of discharge / outcome (one form per medication).

medi_stopreason_oth

text

Please specify other reason

[medi_stopreason] = ‘88’

This refers to the reason for stopping treatment.

If Other, please specify the reason for stopping treatment.

medication

MEDICATION: Record medications administered or prescribed from day of presentation to day of discharge / outcome (one form per medication).

medi_frequency

text

Frequency

[medi_treat]=’1’

Refers to the frequency of specified medicine administration in a 24-hour period (00:00 to 24:00 hours). Examples include ‘every 4 hours’, ‘twice daily’ etc.

Indicate the frequency of specified medicine administration in a 24-hour period (00:00 to 24:00 hours). Examples include ‘every 4 hours’, ‘twice daily’ etc.

treatment

1

1

1

1

medication

MEDICATION: Record medications administered or prescribed from day of presentation to day of discharge / outcome (one form per medication).

medi_dose

number

Dose

number

0

[medi_treat]=’1’

This refers to the dosage of the medication administered any time during the patient’s admission in the clinical facility (hospital), including in the emergency department, and prescribed on discharge.

Write the dose; do not include units as this is asked in the following question.

treatment

1

1

1

1

1

1

1

medication

MEDICATION: Record medications administered or prescribed from day of presentation to day of discharge / outcome (one form per medication).

medi_units

dropdown

Units

1, mg | 2, g | 3, µg | 4, IU | 5, mg/kg | 6, mg/day | 7, mL | 8, mL/h | 9, % | 10, tablets | 88, Other

[medi_treat]=’1’

This refers to the dosage of the medication administered any time during the patient’s admission in the clinical facility (hospital), including in the emergency department, and prescribed on discharge.

Write the units of the dosage.

treatment

1

1

1

medication

MEDICATION: Record medications administered or prescribed from day of presentation to day of discharge / outcome (one form per medication).

medi_units_oth

text

Units (other)

[medi_units]=’88’

This refers to the dosage of the medication administered any time during the patient’s admission in the clinical facility (hospital), including in the emergency department, and prescribed on discharge.

Write the units of the dosage.

treatment

1

1

medication

MEDICATION: Record medications administered or prescribed from day of presentation to day of discharge / outcome (one form per medication).

medi_numdoses

number

Total number of doses (Number of times the drug was injected / swallowed / infused / inserted / applied / inhaled)

number

0

[medi_treat]=’1’

This refers to the total number of doses of the medication which administered any time during the patient’s admission in the clinical facility (hospital), including in the emergency department, and prescribed on discharge.

Write the total number of doses of the medication. If the same medication was administered through different routes, indicate the total number of doses from all routes of administration (injected / swallowed / infused / inserted / applied / inhaled).

treatment

1

1

1

medication

MEDICATION: Record medications administered or prescribed from day of presentation to day of discharge / outcome (one form per medication).

medi_offlab

radio

Was this an off-label or compassionate use of the medication?

1, Yes | 0, No | 99, Unknown

This refers to the practice of prescribing or using a drug or a vaccine for an indication that is not specified in the national regulatory licensing.

Select ‘Yes’ if this medication was used for an indication that is not specified in the national regulatory licensing.

1

1

1

1

1

1

medication

MEDICATION: Record medications administered or prescribed from day of presentation to day of discharge / outcome (one form per medication).

medi_offlab_spec1

text

Specify the off-label or compassionate use medication

[medi_offlab]=’1’

This refers to the practice of prescribing or using a drug or a vaccine for an indication that is not specified in the national regulatory licensing.

Specify medication which was used for an indication that is not specified in the national regulatory licensing.

1

1

1

1

1

1

pathogen_testing

PATHOGEN TESTING: Results of all types of sample and pathogen testing

test_collectiondate

date_dmy

Collection date

date_dmy

today

This refers to the date of collection of a clinical specimen for pathogen testing.

Enter the date when the samples were collected. This may be different to the day in which the results are reported. (Use the format DD/MM/YYYY)

1

1

1

1

1

1

1

1

1

pathogen_testing

PATHOGEN TESTING: Results of all types of sample and pathogen testing

test_biospecimentype

user_list

Biospecimen type

pathogens_SampleType

This refers to the type of a clinical specimen collected for pathogen testing. Nasal / Nasopharyngeal (NP) swab refers to collection biological material from within the nasal passages/nasopharynx. Throat swab refers to collection biological material from within the throat/oropharynx. Combined nasal/NP + throat swab refers to collection using both nasal / nasopharyngeal (NP) swab and throat swab. Sputum refers to material coughed up from the lungs and expectorated via the mouth. Bronchoalveolar Lavage (BAL) refers to washing out of the lungs with saline or mucolytic agents for diagnostic or therapeutic purposes. Endotracheal aspirate (ETA) refers to collection of specimen from endotracheal tube. Eye swab refers to collection of biological sample from the surface of the eye. Lesion swab refers to collection of biological sample from a lesion on the skin or mucous membrane. Semen refers to the secretion of male reproductive organs discharged upon ejaculation. Faeces / rectal swab refers to biological sample collected from faecal matter or from the rectum by swabbing.

Select the single most appropriate option that represents the type of clinical specimen collected for pathogen testing.

1

1

1

1

1

1

1

1

1

pathogen_testing

PATHOGEN TESTING: Results of all types of sample and pathogen testing

test_pathtested

user_list

Pathogen tested / detected

pathogens_All

This refers to the pathogen(s) tested for using the biological sample.

Indicate the pathogen(s) which were tested for using the biological sample.

1

1

1

1

1

1

1

1

1

1

pathogen_testing

PATHOGEN TESTING: Results of all types of sample and pathogen testing

test_labtestmethod

radio

Lab test method

1, PCR (NAAT) | 3, Culture | 6, RDT | 7, ELISA | 8,Other NAAT | 99, Unknown

This refers to the laboratory method used to test for the pathogen.

Select the single most appropriate option that represents the laboratory method used to test for the pathogen.

1

1

1

1

1

1

1

1

1

pathogen_testing

PATHOGEN TESTING: Results of all types of sample and pathogen testing

test_marker

checkbox

Lab marker

1, NS1 Ag | 2, IgG | 3, IgM | 6, IgA | 4, Viral load / serotype (PCR/NAAT) | 5, Not applicable | 99, Unknown

This refers to the laboratory marker used to test for the pathogen

Select the single most appropriate option that represents the laboratory marker used to test for the pathogen.

1

1

1

1

1

1

1

1

1

1

pathogen_testing

PATHOGEN TESTING: Results of all types of sample and pathogen testing

test_naat

radio

NAAT subtype

1, RT-PCR| 2, LAMP | 3, TMA / TMP | 88, Other | 99, Unknown

[test_labtestmethod]=’1’ or [test_labtestmethod]=’8’

1

pathogen_testing

PATHOGEN TESTING: Results of all types of sample and pathogen testing

test_naat_other

text

Specify other NAAT subtype

[test_naat]=’88’

1

pathogen_testing

PATHOGEN TESTING: Results of all types of sample and pathogen testing

test_result

radio

Pathogen test result

1, Detected | 0, Not detected | 2, Equivocal | 99, Unknown

This refers to the results of the pathogen(s) tested for using the biological sample.

Select the single most appropriate option that represents results of the pathogen(s) tested for using the biological sample.

1

1

1

1

1

1

1

1

1

1

pathogen_testing

PATHOGEN TESTING: Results of all types of sample and pathogen testing

test_denguetyp

radio

Dengue virus type

1, DENV1 | 2, DENV2 | 3, DENV3 | 4, DENV4

[test_labtestmethod] = ‘1’ and [test_pathtested]=’96’

This refers to the serotype label of the viral species of Dengue virus, which is a single-stranded, positive-sense RNA virus of the Flaviviridae family and Flavivirus genus, detected using the PCR test.

Select the single most appropriate option that represents the serotype label of the viral species of Dengue virus detected using the PCR test.

SNOMED

60588009, Dengue virus, type 1 (organism) | 41328007, Dengue virus, type 2 (organism) | 8467002, Dengue virus, type 3 (organism) | 36700002, Dengue virus, type 4 (organism)

1

1

1

pathogen_testing

PATHOGEN TESTING: Results of all types of sample and pathogen testing

test_fluresist

radio

If pathogen detected is influenza: Oseltamivir resistance identified

1, Yes | 0, No | 3, Not Tested | 99, Unknown

[test_pathtested]=’183’ or [test_pathtested]=’184’ or [test_pathtested]=’185’ or [test_pathtested]=’186’ or [test_pathtested]=’187’ or [test_pathtested]=’188’ or [test_pathtested]=’189’ or [test_pathtested]=’190’

Refers to identification of Oseltamivir resistance.

Indicate ‘Yes’ if oseltamivir resistance was identified.

1

1

pathogen_testing

PATHOGEN TESTING: Results of all types of sample and pathogen testing

test_ctvalue

number

Cycle threshold (CT) value

number

10

50

[test_result]=’1’ and [test_labtestmethod]=’1’

This refers to the cycle threshold (CT) for nucleic acid detection in specimen using real-time polymerase chain reaction.

Indicate the CT value.

1

1

1

1

1

1

pathogen_testing

PATHOGEN TESTING: Results of all types of sample and pathogen testing

test_vload

number

Viral load (copies/mL)

number

[test_result]=’1’ and [test_labtestmethod]=’1’

This refers to the quantity of virus in a given volume of fluid

Indicate the Viral load.

1

1

1

1

pathogen_testing

PATHOGEN TESTING: Results of all types of sample and pathogen testing

test_genrep

radio

Sequence available in genomic data repository

1, Yes | 0, No

This refers to availability of the pathogen genomic sequence in a data repository.

Indicate ‘Yes’ if the sequence is available in a genomic data repository.

1

1

pathogen_testing

PATHOGEN TESTING: Results of all types of sample and pathogen testing

test_genrep_db

user_list

Genomic repository

pathogens_GenomicRepository

[test_genrep]=’1’

Refers to the genomic repository which contains the pathogen sequence data.

Select the genomic repository which contains the pathogen sequence data.

1

1

pathogen_testing

PATHOGEN TESTING: Results of all types of sample and pathogen testing

test_genrep_ref

text

Repository sequence identifier

[test_genrep]=’1’

Refers to the identifier of the sequence in the repository.

Write the identiifer of the sequence in the genomic repository.

1

1

photographs

PHOTOGRAPHS

photo_date

date_dmy

Date of Image

date_dmy

today

Refers to date when the image was captured.

Enter the date when the image was taken. (Use the format DD/MM/YYYY)

1

1

photographs

PHOTOGRAPHS

photo_type

radio

What is being photographed?

1, Skin lesion | 2, Mucosal lesion | 99, Unknown | 88, Other

Refers to type of pathology being captured in the photograph.

Select the single most appropriate option that represents the type of pathology being captured in the photograph.

1

1

photographs

PHOTOGRAPHS

photo_upload

file

Upload image here

Refers to the image / photograph capturing the pathology.

Upload the photograph of the pathology here.

1

1

photographs

PHOTOGRAPHS

photo_site

radio

What part of the body is photographed?

1, Head, neck or face | 2, Inside of mouth | 3, Front torso | 4, Back torso | 5, Right arm or hand | 6, Left arm or hand | 7, Peri-anal | 8, Pubic region | 9, Right leg or foot | 10, Left leg or foot | 99, Unknown | 88, Other

Refers to the part of the body being captured in the photograph.

Select the single most appropriate option that represents the part of the body being captured in the photograph.

1

1

photographs

PHOTOGRAPHS

photo_site_oth

text

Specify other location

[photo_site]=’88’

Refers to the part of the body being captured in the photograph, not specified above.

If ‘Other’, specify the part of the body being captured in the photograph, not specified above.

1

1

photographs

PHOTOGRAPHS

photo_sampleyn

radio

Was a sample of the photographed area taken?

1, Yes | 2, No | 99, Unknown

Refers to a biological sample of the photographed part of the body.

Indicate ‘Yes’ if a biological sample of the photographed part of the body was taken.

1

1

photographs

PHOTOGRAPHS

photo_sampleid

text

Please enter the sample ID

[photo_sampleyn] = ‘1’

Refers to identification number (ID) of the sample.

Write the sample ID.

1

1

photographs

PHOTOGRAPHS

photo_desc

notes

Please provide any other relevant additional description of the photo or it’s location.

Refers to any other relevant additional description of the photo or it’s location, not specified above.

Indicate any other relevant additional description of the photo or it’s location, not specified above.

1

1

outcome

COMPLICATIONS: Experienced at any time from day of presentation to day of discharge / outcome.

compl_neurological

descriptive

Neurological complications

Nervous system

Defined as any complications of the nervous system

Indicate ‘Yes’, if the patient experienced this at any time during hospitalisation.

1

1

1

1

1

1

1

1

outcome

COMPLICATIONS: Experienced at any time from day of presentation to day of discharge / outcome.

compl_strokecva

radio

Stroke / cerebrovascular accident

1, Yes | 0, No | 99, Unknown

Nervous system

Defined as a sudden loss of neurological function secondary to haemorrhage or ischemia in the brain parenchyma due to a vascular event. Stroke may be a clinical diagnosis, with or without supportive radiological findings.

Indicate ‘Yes’, if the patient experienced this at any time during hospitalisation.

SNOMED

230690007, Cerebrovascular accident

C3554760, Stroke

clinical_features

1

1

1

1

1

1

outcome

COMPLICATIONS: Experienced at any time from day of presentation to day of discharge / outcome.

compl_severeneuro

radio

Severe neurological disease

1, Yes | 0, No | 99, Unknown

Nervous system

This refers to various neurological manifestations including meningitis, encephalitis, encephalopathy, acute symptomatic seizures, intracranial haemorrhage or stroke, and Guillain-Barre syndrome (GBS). Meningitis is an inflammatory disease of the leptomeninges, the tissues surrounding the brain and spinal cord, and is defined by an abnormal number of white blood cells in the cerebrospinal fluid (CSF) within an appropriate clinical context and with or without supportive radiological findings. Encephalitis refers to inflammation of the brain. In comparison with meningitis, in encephalitis, abnormalities in brain function are expected, including altered mental status, motor or sensory deficits, altered behaviour and personality changes, and speech or movement disorders. It is defined by an altered mental status lasting ?24 hours along with two of the following criteria: documented fever >/= 38°C (100.4°F); white blood cell count (WBC) in cerebrospinal fluid (CSF) >/= 5 cells/mm^3; generalized or partial seizures not fully attributable to a preexisting seizure disorder; new onset of focal neurological findings; presence of compatible acute lesion on neuroimaging; abnormality on electroencephalography that is consistent with encephalitis and not attributable to another cause. As outlined by the 2013 International Encephalitis Consortium. Seizures are defined as an intermittent abnormality of nervous system physiology characterised by a transient occurrence of sudden, violent, irregular movement of the body, caused by involuntary contraction of muscles due to abnormal excessive or synchronous neuronal activity in the brain. An established history of epilepsy is not required. Stroke refers to a sudden loss of neurological function secondary to haemorrhage or ischemia in the brain parenchyma due to a vascular event. Stroke may be a clinical diagnosis, with or without supportive radiological findings. Intracranial haemorrhage refers to haemorrhage/bleeding occurring within the skull. Intracranial haemorrhage encompasses four broad types of haemorrhage: epidural haemorrhage, subdural haemorrhage, subarachnoid haemorrhage, and intraparenchymal haemorrhage. Guillain-Barre syndrome refers to a rapidly progressive autoimmune disorder of the peripheral nervous system characterized by limb paraesthesia, areflexia, and generalized muscle weakness or paralysis that often begins in the legs and spreads to the arms, torso, and face. Required features include progressive weakness of the arms and/or legs, ranging from minimal weakness of the legs to total paralysis of all four limbs, and including the trunk, bulbar and facial muscles, and external ophthalmoplegia; and areflexia or decreased deep tendon reflexes in weak limbs. Supportive features include symptom progression over days to four weeks; Relatively symmetric, bilateral symptoms; Pain in the trunk or limbs; Cranial nerve symptoms or signs; Autonomic dysfunction; Sensory dysfunction that is mild; No fever at symptom onset; CSF with elevated protein and normal to mildly elevated leukocyte count (usually <5 cells/mm3); Electrodiagnostic abnormalities consistent with GBS; Recovery starting two to four weeks after progression halts.

Indicate ‘Yes’, if the patient experienced this at any time during hospitalisation.

SNOMED

7180009 |Meningitis (disorder)| 45170000 |Encephalitis (disorder)| 81308009 |Disorder of brain (disorder)|41370002 |Myelitis (disorder)|230690007 |Cerebrovascular accident (disorder)|1386000 |Intracranial haemorrhage (disorder)|40956001 |Guillain-Barre syndrome (GBS) (disorder)|

clinical_features

1

1

1

1

1

outcome

COMPLICATIONS: Experienced at any time from day of presentation to day of discharge / outcome.

compl_encephalopathy

radio

Encephalopathy

1, Yes | 0, No | 99, Unknown

Nervous system

Encephalopathy broadly refers brain dysfunction which may be due to a functional and / or structural disorder caused by a vareity of aetiologies, including diseases of other organ systems (e.g. liver disease, kidney disease), medications, chemicals, and injuries. It presents with a range of symptoms including altered mental status, confusion, memory loss, and behavioral changes

Indicate ‘Yes’, if the patient experienced this at any time during hospitalisation.

clinical_features

1

1

1

1

1

1

1

outcome

COMPLICATIONS: Experienced at any time from day of presentation to day of discharge / outcome.

compl_seizure

radio

Seizure

1, Yes | 0, No | 99, Unknown

Nervous system

Defined as an intermittent abnormality of nervous system physiology characterised by a transient occurrence of sudden, violent, irregular movement of the body, caused by involuntary contraction of muscles due to abnormal excessive or synchronous neuronal activity in the brain. An established history of epilepsy is not required.

Indicate ‘Yes’, if the patient experienced this at any time during hospitalisation.

SNOMED

91175000, Seizure

C2748942, Seizure

clinical_features

1

1

1

1

1

1

1

1

1

outcome

COMPLICATIONS: Experienced at any time from day of presentation to day of discharge / outcome.

compl_focalneuro

radio

Focal neurological signs

1, Yes | 0, No | 99, Unknown

Nervous system

Defined as as impairments of nerve, spinal cord, or brain function that affect a specific region of the body, e.g. weakness in the left arm, the right leg, paresis, or plegia, identified in neurological examination.

Indicate ‘Yes’, if the patient experienced this at any time during hospitalisation.

SNOMED

264552009, Neurological deficit

C0746857, Focal neurological deficit

clinical_features

1

1

1

1

1

1

1

1

outcome

COMPLICATIONS: Experienced at any time from day of presentation to day of discharge / outcome.

compl_encephalitis

radio

Encephalitis

1, Yes | 0, No | 99, Unknown

Nervous system

Encephalitis refers to inflammation of the brain. It is defined by an altered mental status lasting greater or equal to 24 hours along with two of the following criteria: documented fever greater or equal to 38° C (100.4°F); white blood cell count (WBC) in cerebrospinal fluid (CSF) greater or equal to 5/mm³; generalized or partial seizures not fully attributable to a preexisting seizure disorder; new onset of focal neurological findings; presence of compatible acute lesion on neuroimaging; abnormality on electroencephalography that is consistent with encephalitis and not attributable to another cause. As outlined by the 2013 International Encephalitis Consortium.

Indicate ‘Yes’, if the patient experienced this at any time during hospitalisation.

SNOMED

45170000, Encephalitis

C0014038, Encephalitis

clinical_features

1

1

1

1

1

1

1

1

outcome

COMPLICATIONS: Experienced at any time from day of presentation to day of discharge / outcome.

compl_meningitis

radio

Meningitis

1, Yes | 0, No | 99, Unknown

Nervous system

Meningitis is defined by an abnormal number of white blood cells in the cerebrospinal fluid (CSF) within an appropriate clinical context and with or without supportive radiological findings.

Indicate ‘Yes’, if the patient experienced this at any time during hospitalisation.

SNOMED

7180009, Meningitis

C0025289, Meningitis

clinical_features

1

1

1

1

1

1

1

1

outcome

COMPLICATIONS: Experienced at any time from day of presentation to day of discharge / outcome.

compl_gbs

radio

Guillain-Barre syndrome (GBS)

1, Yes | 0, No | 99, Unknown

Nervous system

Refers to a rapidly progressive autoimmune disorder of the peripheral nervous system characterized by limb paresthesias, areflexia, and generalized muscle weakness or paralysis that often begins in the legs and spreads to the arms, torso, and face.

Indicate ‘Yes’, if the patient experienced this at any time during hospitalisation.

C0018378

clinical_features

1

1

1

1

1

1

1

outcome

COMPLICATIONS: Experienced at any time from day of presentation to day of discharge / outcome.

compl_cnsinf

radio

CNS infection

1, Yes | 0, No | 99, Unknown

Nervous system

This refers to An infectious process that affects the brain and/or spinal cord, may include encephalitis, poliomyelitis, arachnoiditis, and meningitis.

Indicate ‘Yes’, if the patient experienced this at any time during hospitalisation.

clinical_features

1

outcome

COMPLICATIONS: Experienced at any time from day of presentation to day of discharge / outcome.

compl_atm

radio

Acute Transverse Myelitis (ATM)

1, Yes | 0, No | 99, Unknown

Nervous system

Indicate ‘Yes’, if the patient experienced this at any time during hospitalisation.

1

outcome

COMPLICATIONS: Experienced at any time from day of presentation to day of discharge / outcome.

compl_perneur

radio

Peripheral neuropathy

1, Yes | 0, No | 99, Unknown

Nervous system

Indicate ‘Yes’, if the patient experienced this at any time during hospitalisation.

1

outcome

COMPLICATIONS: Experienced at any time from day of presentation to day of discharge / outcome.

compl_cvs

descriptive

Cardiovascular complications

Cardiovascular

Defined as any complications of the cardiovascular system

Indicate ‘Yes’, if the patient experienced this at any time during hospitalisation.

1

1

1

1

1

1

1

1

outcome

COMPLICATIONS: Experienced at any time from day of presentation to day of discharge / outcome.

compl_myocardial

radio

Myocardial infarction

1, Yes | 0, No | 99, Unknown

Cardiovascular

Defined as myocardial ischaemia leading to injury/necrosis, diagnosed by clinical findings, altered electrocardiography and elevated cardiac enzymes.

Indicate ‘Yes’, if the patient experienced this at any time during hospitalisation.

SNOMED

22298006, Myocardial infarction

C3280935, Myocardial infarction

clinical_features

1

1

1

1

1

outcome

COMPLICATIONS: Experienced at any time from day of presentation to day of discharge / outcome.

compl_cardiacisc

radio

Cardiac ischaemia

1, Yes | 0, No | 99, Unknown

Cardiovascular

Defined as diminished blood and oxygen supply to the heart muscle as indicated by typical symptomatology (e.g. chest pain) and confirmed by an electrocardiogram (showing ischaemic changes, e.g. ST depression or elevation) and/or cardiac enzyme elevation (e.g. raised troponin I).

Indicate ‘Yes’, if the patient experienced this at any time during hospitalisation.

SNOMED

414795007, Myocardial ischaemia

C0746731, Acute myocardial ischaemia

clinical_features

1

1

1

1

1

outcome

COMPLICATIONS: Experienced at any time from day of presentation to day of discharge / outcome.

compl_endocardit

radio

Endocarditis

1, Yes | 0, No | 99, Unknown

Cardiovascular

This refers to an inflammation of the endocardium (inner lining of the heart). It is often caused by a primary disorder or microorganisms including bacteria, viruses, fungi, and rickettsiae Diagnosis of infective endocarditis is according to modified Duke criteria, using evidence from microbiological results, echocardiogram and clinical signs.

Indicate ‘Yes’, if the patient experienced this at any time during hospitalisation.

SNOMED

56819008, Endocarditis

C0014118, Endocarditis

clinical_features

1

1

1

1

1

outcome

COMPLICATIONS: Experienced at any time from day of presentation to day of discharge / outcome.

compl_cardiomyop

radio

Cardiomyopathy

1, Yes | 0, No | 99, Unknown

Cardiovascular

This refers to structural and functional disorders of myocardium commonly diagnosed by echocardiography. Cardiomyopathy can be primary (genetic) or secondary (e.g. following myocardial infarction).

Indicate ‘Yes’, if the patient experienced this at any time during hospitalisation.

SNOMED

85898001, Cardiomyopathy

C3809229, Cardiomyopathy

clinical_features

1

1

1

1

1

outcome

COMPLICATIONS: Experienced at any time from day of presentation to day of discharge / outcome.

compl_chf

radio

Congestive heart failure

1, Yes | 0, No | 99, Unknown

Cardiovascular

Defined as failure of the heart to pump a sufficient amount of blood to meet the needs of the body tissues, resulting in tissue congestion and oedema. Signs and symptoms include shortness of breath, pitting oedema, enlarged tender liver, engorged neck veins, and pulmonary rales. There are many ways to assess cardiac function (e.g. echocardiography, right heart catheterization, functional testing and supportive biochemical tests). However, there is no diagnostic test for heart failure, since it is largely a clinical diagnosis that is based upon a careful history and physical examination.

Indicate ‘Yes’, if the patient experienced this at any time during hospitalisation.

SNOMED

42343007, Congestive heart failure

C3551869, Congestive heart failure

clinical_features

1

1

1

1

1

1

1

outcome

COMPLICATIONS: Experienced at any time from day of presentation to day of discharge / outcome.

compl_cardiarrhy

radio

Cardiac arrhythmia

1, Yes | 0, No | 99, Unknown

Cardiovascular

Refers to any variation from the normal rate or rhythm (which may include the origin of the impulse and/or its subsequent propagation) in the heart, confirmed by electrocardiographic monitoring.

Indicate ‘Yes’, if the patient experienced this at any time during hospitalisation.

SNOMED

698247007, Cardiac arrhythmia

C3275765, Arrhythmia

clinical_features

1

1

1

1

1

1

1

1

outcome

COMPLICATIONS: Experienced at any time from day of presentation to day of discharge / outcome.

compl_cardiarrest

radio

Cardiac arrest

1, Yes | 0, No | 99, Unknown

Cardiovascular

Cardiopulmonary arrest or circulatory arrest is defined as the sudden cessation of cardiac activity in an individual who becomes unresponsive, without normal breathing and no signs of circulation.

Indicate ‘Yes’, if the patient experienced this at any time during hospitalisation.

SNOMED

410429000, Cardiac arrest

C4015675, Cardiac arrest

clinical_features

1

1

1

1

1

1

1

1

1

outcome

COMPLICATIONS: Experienced at any time from day of presentation to day of discharge / outcome.

compl_myocarditis

radio

Myocarditis

1, Yes | 0, No | 99, Unknown

Cardiovascular

This refers to inflammation of the muscle tissue of the heart (myocarditis) / an inflammatory process affecting the pericardium (pericarditis). It may be diagnosed clinically, with assistance from an echocardiogram, EKG, laboratory or radiological tests.

Indicate ‘Yes’, if the patient experienced this at any time during hospitalisation.

SNOMED

50920009, Myocarditis;

C0027059, Myocarditis;

clinical_features

1

1

1

1

1

1

1

1

outcome

COMPLICATIONS: Experienced at any time from day of presentation to day of discharge / outcome.

compl_pericarditis

radio

Pericarditis

1, Yes | 0, No | 99, Unknown

Cardiovascular

This refers to inflammation of the muscle tissue of the heart (myocarditis) / an inflammatory process affecting the pericardium (pericarditis). It may be diagnosed clinically, with assistance from an echocardiogram, EKG, laboratory or radiological tests.

Indicate ‘Yes’, if the patient experienced this at any time during hospitalisation.

SNOMED

3238004, Pericarditis;

C4230735, Pericarditis;

clinical_features

1

1

1

1

1

1

1

1

outcome

COMPLICATIONS: Experienced at any time from day of presentation to day of discharge / outcome.

compl_respiratory

descriptive

Respiratory complications

Respiratory

Defined as any complications of the respiratory system

Indicate ‘Yes’, if the patient experienced this at any time during hospitalisation.

1

1

1

1

1

1

1

1

outcome

COMPLICATIONS: Experienced at any time from day of presentation to day of discharge / outcome.

compl_pneum

radio

Pneumonia / pneumonitis

1, Yes | 0, No | 99, Unknown

Respiratory

Pneumonia is an infection of one or both lungs that causes the air sacs to become inflamed and fill with fluid or pus, making it difficult to breathe. This inflammation is commonly caused by bacteria, viruses, or fungi and can result in symptoms such as cough, fever, chills, and shortness of breath.

Indicate ‘Yes’, if the patient experienced this at any time during hospitalisation.

SNOMED

233604007

1

1

1

1

1

1

outcome

COMPLICATIONS: Experienced at any time from day of presentation to day of discharge / outcome.

compl_pneum_etio

radio

Is the etiological pathogen different to the primary diagnosis

1, Yes | 2, No | 99, Unknown

Respiratory

Pneumonia is an infection of one or both lungs that causes the air sacs to become inflamed and fill with fluid or pus, making it difficult to breathe. This inflammation is commonly caused by bacteria, viruses, or fungi and can result in symptoms such as cough, fever, chills, and shortness of breath.

Indicate ‘Yes’, if the patient experienced this at any time during hospitalisation.

1

outcome

COMPLICATIONS: Experienced at any time from day of presentation to day of discharge / outcome.

compl_pneum_type

radio

Etiology of pneumonia

1, Viral | 2, Bacterial | 3, Fungal

Respiratory

Pneumonia is an infection of one or both lungs that causes the air sacs to become inflamed and fill with fluid or pus, making it difficult to breathe. This inflammation is commonly caused by bacteria, viruses, or fungi and can result in symptoms such as cough, fever, chills, and shortness of breath.

Indicate ‘Yes’ if the pathogen causing pneumonia as a complication is different from the pathogen of interest at admission.

1

1

1

1

1

outcome

COMPLICATIONS: Experienced at any time from day of presentation to day of discharge / outcome.

compl_pneum_acq

radio

Acquisition setting of pneumonia

1, Community acquired | 2, Hospital acquired | 3, Ventilator acquired | 99, Unknown

Respiratory

This refers to the setting in which the pneumonia was acquired: community, hospital, ventilator-associated, or unknown.

1

outcome

COMPLICATIONS: Experienced at any time from day of presentation to day of discharge / outcome.

compl_pneumothor

radio

Pneumothorax

1, Yes | 0, No | 99, Unknown

Respiratory

Defined as the abnormal presence of air in the pleural cavity (between the lungs and the chest wall), causing collapse of the lung. It may be diagnosed clinically, usually with radiological confirmation.

Indicate ‘Yes’, if the patient experienced this at any time during hospitalisation.

SNOMED

36118008, Pneumothorax

C3553768, Pneumothorax

clinical_features

1

1

1

1

1

outcome

COMPLICATIONS: Experienced at any time from day of presentation to day of discharge / outcome.

compl_pleuraleff

radio

Pleural effusion

1, Yes | 0, No | 99, Unknown

Respiratory

Defined as increased amounts of fluid within the pleural cavity. Symptoms include shortness of breath, cough, and chest pain. It is usually caused by lung infections, congestive heart failure, pleural and lung tumours, connective tissue disorders, and trauma. It may be diagnosed clinically, with or without radiological or interventional confirmation.

Indicate ‘Yes’, if the patient experienced this at any time during hospitalisation.

SNOMED

60046008, Pleural effusion

C0032227, Pleural effusion

clinical_features

1

1

1

1

1

1

1

1

outcome

COMPLICATIONS: Experienced at any time from day of presentation to day of discharge / outcome.

compl_copneumoni

radio

Cryptogenic organising pneumonia (COP)

1, Yes | 0, No | 99, Unknown

Respiratory

This refers to an idiopathic diffuse interstitial lung disease, diagnosed radiologically (multiple consolidative or ground glass opacities) or histologically (granulation tissue and chronic inflammatory infiltrate in alveoli). Formerly known as bronchiolitis obliterans organizing pneumonia (BOOP).

Indicate ‘Yes’, if the patient experienced this at any time during hospitalisation.

SNOMED

719218000, Cryptogenic organizing pneumonia

C0242770, Cryptogenic organizing pneumonia

clinical_features

1

1

1

1

1

outcome

COMPLICATIONS: Experienced at any time from day of presentation to day of discharge / outcome.

compl_bronchioli

radio

Bronchiolitis

1, Yes | 0, No | 99, Unknown

Respiratory

This refers to Inflammation of the bronchioles. In adults, bronchiolitis is a general term used to describe a nonspecific Inflammation of the bronchioles characterized by swelling of the bronchioles and mucus accumulation. It is usually caused by the respiratory syncytial virus and affects children. Signs and symptoms include coughing, wheezing, and shortness of breath. In the majority of cases, open or thoracoscopic lung biopsy is required to make a definitive diagnosis, although tissue confirmation may not be necessary in patients with a clear predisposition and typical radiological findings. In infants and children, bronchiolitis is defined as an illness in children <2 years of age, characterized by wheezing and airway obstruction due to primary infection or reinfection with a viral or bacterial pathogen, resulting in inflammation of the small airways/bronchioles. This is a clinical diagnosis, generally in children < 2 years old.

Indicate ‘Yes’, if the patient experienced this at any time during hospitalisation.

SNOMED

4120002, Bronchiolitis

C0006271, Bronchiolitis

clinical_features

1

1

1

1

1

outcome

COMPLICATIONS: Experienced at any time from day of presentation to day of discharge / outcome.

compl_ards

radio

Acute Respiratory Distress Syndrome (ARDS)

1, Yes | 0, No | 99, Unknown

Respiratory

Acute respiratory distress syndrome (ARDS) is a non-cardiogenic pulmonary oedema and diffuse lung inflammation syndrome that often complicates critical illness. Diagnosis of ARDS is based on fulfilling three criteria: a) Acute onset (within 1 week) b) Bilateral opacities on chest radiography or computed tomography (CT), or bilateral B lines and/or consolidations on ultrasound not fully explained by effusions, atelectasis, or nodules/masses. c)PaO2/FiO2 (arterial to inspired oxygen) ratio of ?300 or SpO2/FiO2 (pulse oximetric saturation to inspired oxygen) ratio of ?315.

Indicate ‘Yes’, if the patient experienced this at any time during hospitalisation.

SNOMED

67782005, Acute respiratory distress

C1848829, Acute respiratory distress

clinical_features

1

1

1

1

1

1

1

1

outcome

COMPLICATIONS: Experienced at any time from day of presentation to day of discharge / outcome.

compl_git

descriptive

Gastrointestinal complications

Gastrointestinal

Defined as any complications of the gastrointestinal system

Indicate ‘Yes’, if the patient experienced this at any time during hospitalisation.

1

1

1

1

1

1

1

1

outcome

COMPLICATIONS: Experienced at any time from day of presentation to day of discharge / outcome.

compl_ascite

radio

Ascites

1, Yes | 0, No | 99, Unknown

Gastrointestinal

This refers to pathological increase in amount of fluid in the abdominal cavity (ascites). It may be diagnosed clinically, with or without radiological or interventional confirmation. Symptoms associated with ascites include increasing abdominal girth, abdominal discomfort and distension, shortness of breath.

Indicate ‘Yes’, if the patient experienced this at any time during hospitalisation.

SNOMED

389026000, Ascites

C3554541, Peritoneal effusion

clinical_features

1

1

outcome

COMPLICATIONS: Experienced at any time from day of presentation to day of discharge / outcome.

compl_pancreatit

radio

Pancreatitis

1, Yes | 0, No | 99, Unknown

Gastrointestinal

This refers to acute inflammation of the pancreas. Acute pancreatitis is diagnosed clinically with supporting biochemical (e.g serum amylase or serum lipase) and/or radiological and/or histological evidence. All evidence should be considered together, since no single feature is diagnostic of acute pancreatitis.

Indicate ‘Yes’, if the patient experienced this at any time during hospitalisation.

SNOMED

75694006, Pancreatitis

C4011703, Pancreatitis

clinical_features

1

1

1

1

1

outcome

COMPLICATIONS: Experienced at any time from day of presentation to day of discharge / outcome.

compl_acutehepat

radio

Acute hepatitis

1, Yes | 0, No | 99, Unknown

Gastrointestinal

This refers to acute hepatic injury from inflammation resulting in fever, abdominal pain, jaundice accompanied with increased liver function tests (serum alanine transaminase (ALT) and / or aspartate transaminase (AST) activity). Etiologies include viral hepatitis, drugs, toxins, and autoimmune disorders.

Indicate ‘Yes’, if the patient experienced this at any time during hospitalisation.

SNOMED

37871000, Acute hepatitis

C0267797, Acute hepatitis

clinical_features

1

1

1

1

1

outcome

COMPLICATIONS: Experienced at any time from day of presentation to day of discharge / outcome.

compl_severeliver

radio

Severe liver disease (new onset)

1, Yes | 0, No | 99, Unknown

Gastrointestinal

Defined as new onset cirrhosis and portal hypertension with variceal bleeding, ascites, jaundice or status post liver transplantation.

Indicate ‘Yes’, if the patient experienced this at any time during hospitalisation.

SNOMED

235856003 | Disorder of liver (disorder) | 24484000 |Severe (severity modifier) (qualifier value)|

CL1793619, Severe liver disease

clinical_features

1

1

1

1

1

1

1

1

outcome

COMPLICATIONS: Experienced at any time from day of presentation to day of discharge / outcome.

compl_hepaticenc

radio

Hepatic encephalopathy (any grade)

1, Yes | 0, No | 99, Unknown

[compl_severeliver] = ‘1’

Gastrointestinal

This refers to a neuropsychiatric syndrome caused by advanced liver insufficiency and/or portosystemic shunt without evidence of other primary neurological disease. Clinical features include lethargy; confusion (can progress to coma); asterixis; pathologic nystagmus; brisk oculovestibular reflexes; decorticate and decerebrate posturing; muscle spasticity; and bilateral extensor plantar reflexes.

Indicate ‘Yes’, if the patient experienced this at any time during hospitalisation.

SNOMED

13920009, Hepatic encephalopathy

C0019151, Hepatic encephalopathy

clinical_features

1

1

1

1

1

outcome

COMPLICATIONS: Experienced at any time from day of presentation to day of discharge / outcome.

compl_jaundice

radio

Jaundice

1, Yes | 0, No | 99, Unknown

Gastrointestinal

This refers to a clinical manifestation of hyperbilirubinemia, characterized by the yellowish staining of the skin, mucous membrane and/or sclera.

Indicate ‘Yes’, if the patient experienced this at any time during hospitalisation.

SNOMED

18165001, Jaundice

C3549846, Jaundice

clinical_features

1

1

1

1

1

outcome

COMPLICATIONS: Experienced at any time from day of presentation to day of discharge / outcome.

compl_liverdysfu

radio

Liver dysfunction

1, Yes | 0, No | 99, Unknown

Gastrointestinal

This refers to a finding that indicates abnormal liver function, may refer to any of the following: Jaundice; Hyperbilirubinemia (blood bilirubin level twice the upper limit of the normal range); An increase in alanine transaminase (ALT) or aspartate transaminase (AST) that is twice the upper limit of the normal range.

Indicate ‘Yes’, if the patient experienced this at any time during hospitalisation.

SNOMED

235856003, Disorder of liver (disorder)

C3552261, Liver and intrahepatic bile duct disorder

clinical_features

1

1

1

1

outcome

COMPLICATIONS: Experienced at any time from day of presentation to day of discharge / outcome.

compl_heme

descriptive

Haematological complications

Haematology

Defined as any complications of the haematological system

Indicate ‘Yes’, if the patient experienced this at any time during hospitalisation.

1

1

1

1

1

1

1

outcome

COMPLICATIONS: Experienced at any time from day of presentation to day of discharge / outcome.

compl_thrombemb

radio

Thromboembolism

1, Yes | 0, No | 99, Unknown

Haematology

Defined as the occlusion of the lumen of a blood vessel by a thrombus that has migrated from a distal site via the blood stream.

Indicate ‘Yes’, if the patient experienced this at any time during hospitalisation.

SNOMED

371039008, Thromboembolic disorder

C3550383, Thromboembolism

clinical_features

1

1

1

1

1

1

outcome

COMPLICATIONS: Experienced at any time from day of presentation to day of discharge / outcome.

compl_thrombemb_pe

radio

Pulmonary embolism (PE)

1, Yes | 0, No | 99, Unknown

[compl_thrombemb]=1

Haematology

Defined as the occlusion of a pulmonary artery by thrombus, air or fat. Physician diagnosis based on clinical signs and/or radiological tests (e.g. computed tomographic pulmonary angiography and/or ventilation/perfusion scanning).

Indicate ‘Yes’, if the patient experienced this at any time during hospitalisation.

SNOMED

233935004, Pulmonary thromboembolism

C0524702, Pulmonary thromboembolism

clinical_features

1

1

1

1

1

outcome

COMPLICATIONS: Experienced at any time from day of presentation to day of discharge / outcome.

compl_thrombemb_dvt

radio

Deep vein thrombosis (DVT)

1, Yes | 0, No | 99, Unknown

[compl_thrombemb]=1

Haematology

Defined as the presence of a blood clot in a deep vein, predominantly in the lower extremity, but may include the pelvis or upper extremity. Symptoms may include pain, swelling, warmth, and redness in the affected area. Physician diagnosis based on clinical signs and/or appropriate diagnostic imaging e.g. ultrasonography.

Indicate ‘Yes’, if the patient experienced this at any time during hospitalisation.

SNOMED

128053003, Deep venous thrombosis

C3536663, Acute deep venous thrombosis

clinical_features

1

1

1

1

1

outcome

COMPLICATIONS: Experienced at any time from day of presentation to day of discharge / outcome.

compl_thrombemb_oth

radio

Other thromboembolism (not PE or DVT)

1, Yes | 0, No | 99, Unknown

[compl_thrombemb]=1

Haematology

This refers to thromboembolic diagnoses not specified above.

Indicate ‘Yes’, if the patient experienced this at any time during hospitalisation.

clinical_features

1

1

1

1

1

outcome

COMPLICATIONS: Experienced at any time from day of presentation to day of discharge / outcome.

compl_thrombemb_spec

text

Specify other thromboembolism

[compl_thrombemb_oth]=’1’

Haematology

This refers to the other thromboembolic diagnoses not specified above.

If ‘Other’, write the other thromboembolic diagnoses the patient experienced at any time during hospitalisation.

clinical_features

1

1

1

1

1

outcome

COMPLICATIONS: Experienced at any time from day of presentation to day of discharge / outcome.

compl_severebleed

radio

Severe bleeding (requiring intervention)

1, Yes | 0, No | 99, Unknown

Haematology

Defined as bleeding resulting in haemodynamic compromise necessitating intervention, namely transfusion. This includes World Health Organisation (WHO) Bleeding Scale grade 3 or 4.

Indicate ‘Yes’, if the patient experienced this at any time during hospitalisation.

SNOMED

10421000132103, Haemorrhage requiring transfusion

C4023144, Bleeding requiring red cell transfusion

clinical_features

1

1

1

1

1

1

1

1

outcome

COMPLICATIONS: Experienced at any time from day of presentation to day of discharge / outcome.

compl_severebleed_site

checkbox

Severe bleeding site(s)

1, Skin | 7, Petechiae | 2, Nose | 3, Gums | 4, GI tract | 5, Urinary tract | 6, Vagina | 88, Other(s) | 99, Unknown

[compl_severebleed] = ‘1’

Haematology

This refers to the location of bleeding/haemorrhage site(s). Petechiae refer to small reddish or purplish spots in skin or mucous membrane as a result of localised haemorrhage. Nose bleeding refers to haemorrhage localized in the nose. Gum bleeding refers to haemorrhage affecting the gingiva. Gastrointestinal (GI) bleeding refers to haemorrhage in any segment of the gastrointestinal tract from oesophagus to rectum. Urinary tract bleeding refers to haemorrhage originating from any part of the urinary system. Vaginal bleeding refers to haemorrhage originating from vagina, unrelated to normal menstruation.

Select the most appropriate option(s) corresponding to the location of bleeding/haemorrhage site(s).

SNOMED

297968009, Bleeding skin | 271813007 Petechiae | 249366005, Bleeding from nose | 86276007, Bleeding gums | 74474003, Gastrointestinal haemorrhage |34436003, blood in urine | 289530006, Bleeding from vagina

C0574741, Bleeding skin | C3808808, Epistaxis | C0017565, Gingival haemorrrhage | C0017181, Gastrointestinal haemorrhage |C3805433, haematuria | C0566961, Fresh bleeding from vagina

clinical_features

1

1

1

1

1

1

outcome

COMPLICATIONS: Experienced at any time from day of presentation to day of discharge / outcome.

compl_severebleed_site_oth

text

Specify other site(s) of bleeding

[compl_severebleed_site(88)]=’1’

Haematology

This refers to the location of bleeding/haemorrhage site(s).

If ‘Other’, Write the other location of site(s) where the patient has experienced bleeding/haemorrhage at any time from onset of this illness and presentation or admission.

clinical_features

1

1

1

1

1

1

outcome

COMPLICATIONS: Experienced at any time from day of presentation to day of discharge / outcome.

compl_anaemia

radio

Anaemia

1, Yes | 0, No | 99, Unknown

Haematology

Defined as a reduction in the number of red blood cells, the amount of haemoglobin, and/or the volume of packed red blood cells. Signs and symptoms of anaemia may include pallor of the skin and mucous membranes, shortness of breath, palpitations of the heart, soft systolic murmurs, lethargy, and fatigability. The World Health Organization thresholds are used for defining anaemia, in adult males aged over 15 years anaemia is defined by a haemoglobin <130g/L (<8.1mmol/L); for non-pregnant females aged over 15 years thresholds are <120g/L (<7.4mmol/L), for children aged under 5 years and pregnant women as a haemoglobin <110 g/L (6.8 mmol/L)

Indicate ‘Yes’, if the patient experienced this at any time during hospitalisation.

SNOMED

271737000, Anaemia

C4229468, Anaemia

clinical_features

1

1

1

1

1

outcome

COMPLICATIONS: Experienced at any time from day of presentation to day of discharge / outcome.

compl_coagulatio

radio

Coagulation disorder / DIC

1, Yes | 0, No | 99, Unknown

Haematology

Coagulopathy (bleeding disorder) is defined as a condition in which there is a deviation from or interruption of the normal coagulation properties of the blood (normal blood clotting is disrupted). Disseminated intravascular coagulation (DIC) is a specific type of coagulopathy which blood starts to coagulate throughout the whole body. Acute DIC is confirmed by demonstrating increased thrombin generation (e.g. decreased fibrinogen) and increased fibrinolysis (e.g. elevated fibrin degradation products and D-dimer). The diagnosis of chronic DIC may be largely based upon evidence of microangiopathy on the blood film and increased levels of fibrin degradation products and particularly D-dimer.

Indicate ‘Yes’, if the patient experienced this at any time during hospitalisation.

SNOMED

64779008, Blood coagulation disorder

C4229995, Coagulation disorder

clinical_features

1

1

1

1

1

1

1

1

1

outcome

COMPLICATIONS: Experienced at any time from day of presentation to day of discharge / outcome.

compl_renalgut

descriptive

Renal/genitourinary complications

Renal/Genitourinary

Defined as any complications of the renal/genitourinary system

Indicate ‘Yes’, if the patient experienced this at any time during hospitalisation.

1

1

1

1

1

1

1

1

outcome

COMPLICATIONS: Experienced at any time from day of presentation to day of discharge / outcome.

compl_acuterenal

radio

Acute renal injury / acute renal failure

1, Yes | 0, No | 99, Unknown

Renal/Genitourinary

Acute kidney injury is defined when one of the following criteria is met: Serum creatinine rises by >= 26umol/L or 0.3mg/dL within 48 hours; or serum creatinine rises >= 1.5 fold from the reference value, which is known or presumed to have occurred within the prior 7 days; or urine output is <0.5ml/kg/hr for >6 consecutive hours.

Indicate ‘Yes’, if the patient experienced this at any time during hospitalisation.

SNOMED

14669001 |Acute kidney injury (disorder)|

C2609414 | Acute kidney injury

clinical_features

1

1

1

1

1

1

1

1

1

outcome

COMPLICATIONS: Experienced at any time from day of presentation to day of discharge / outcome.

compl_uti

radio

Urinary tract infection

1, Yes | 0, No | 99, Unknown

Renal/Genitourinary

This refers to inflammatory responses of the epithelium of the urinary tract to microbial invasions. They are often bacterial infections with associated bacteruria and pyuria.

Indicate ‘Yes’, if the patient experienced this at any time during hospitalisation.

SNOMED

68566005, Urinary tract infectious disease (disorder)

C0042029, Urinary tract infection

clinical_features

1

outcome

COMPLICATIONS: Experienced at any time from day of presentation to day of discharge / outcome.

compl_urineret

radio

Urinary retention

1, Yes | 0, No | 99, Unknown

Renal/Genitourinary

This refers to accumulation of urine within the bladder because of the inability to urinate.

Indicate ‘Yes’, if the patient experienced this at any time during hospitalisation.

1

outcome

COMPLICATIONS: Experienced at any time from day of presentation to day of discharge / outcome.

compl_urineret_spec

text

please specify

[compl_urineret] = ‘1’

Renal/Genitourinary

This refers to accumulation of urine within the bladder because of the inability to urinate.

If ‘Yes’, please specify

1

outcome

COMPLICATIONS: Experienced at any time from day of presentation to day of discharge / outcome.

compl_ent

radio

Ear/Nose/Throat complications

1, Yes | 0, No | 99, Unknown

ENT

Defined as any complications of the ear / nose and throat system

Indicate ‘Yes’, if the patient experienced this at any time during hospitalisation.

1

outcome

COMPLICATIONS: Experienced at any time from day of presentation to day of discharge / outcome.

compl_deepneck

radio

Deep neck space infections

1, Yes | 0, No | 99, Unknown

ENT

This refers to an infection of the deep fascial planes in the neck.

Indicate ‘Yes’, if the patient experienced this at any time during hospitalisation.

1

outcome

COMPLICATIONS: Experienced at any time from day of presentation to day of discharge / outcome.

compl_msk

descriptive

Musculoskeletal complication

Musculoskeletal

Defined as any complications of the musculoskeletal system

Indicate ‘Yes’, if the patient experienced this at any time during hospitalisation.

1

1

1

1

1

outcome

COMPLICATIONS: Experienced at any time from day of presentation to day of discharge / outcome.

compl_rhabdomyol

radio

Rhabdomyolysis

1, Yes | 0, No | 99, Unknown

Musculoskeletal

Rhabdomyolysis is a syndrome characterised by muscle necrosis and the release of myoglobin into the blood, resulting from muscle injury. Diagnosis is made in a patient with either an acute neuromuscular illness or dark urine without other symptoms, plus a marked acute elevation in creatine kinase. The creatine kinase is typically at least five times the upper limit of normal (there is no diagnostic threshold to establish the diagnosis, however). Muscle biopsy, electromyography, radiological imaging and the presence of myoglobinuria are not required for the diagnosis.

Indicate ‘Yes’, if the patient experienced this at any time during hospitalisation.

SNOMED

240131006, Rhabdomyolysis

C4014084, Rhabdomyolysis

clinical_features

1

1

1

1

1

outcome

COMPLICATIONS: Experienced at any time from day of presentation to day of discharge / outcome.

compl_myositis

radio

Myositis

1, Yes | 0, No | 99, Unknown

Musculoskeletal

Myositis is defined as an inflammatory process affecting the skeletal muscles. Causes include infections, injuries, and autoimmune disorders. It may be a clinical diagnosis with supporting evidence from laboratory tests e.g. elevated serum creatine kinase; histological confirmation is not required to make the diagnosis. Myositis can occur without subsequent progression to rhabdomyolysis.

Indicate ‘Yes’, if the patient experienced this at any time during hospitalisation.

SNOMED

26889001, Myositis

C4014723, Myositis

clinical_features

1

1

1

1

1

outcome

COMPLICATIONS: Experienced at any time from day of presentation to day of discharge / outcome.

compl_skin

descriptive

Skin complication

Skin

Defined as any complications of the skin

Indicate ‘Yes’, if the patient experienced this at any time during hospitalisation.

1

1

outcome

COMPLICATIONS: Experienced at any time from day of presentation to day of discharge / outcome.

compl_cellulitis

radio

Cellulitis

1, Yes | 0, No | 99, Unknown

Skin

Defined as an acute, diffuse, and suppurative inflammation of loose connective tissue, particularly the deep subcutaneous tissues, and sometimes muscle, which is most commonly seen as a result of infection. Diagnosis is made on clinical signs and symptoms, it can be supported by microbiological evidence.

Indicate ‘Yes’, if the patient experienced this at any time during hospitalisation.

SNOMED

128045006, Cellulitis

C0007642, Cellulitis

clinical_features

1

1

outcome

COMPLICATIONS: Experienced at any time from day of presentation to day of discharge / outcome.

compl_cellulitis_site

checkbox

Site(s) of cellulitis

1, Skin | 2, Nose | 3, Gums | 4, GI tract | 5, Urinary tract | 6, Vagina | 99, Unknown | 88, Other

[compl_cellulitis] = ‘1’

Skin

This refers to the site(s) in which cellulitis was identified.

Select the most appropriate site(s) in which cellulitis was identified at any time during hospitalisation. If ‘Other’, Specify the other site(s) in the space provided below.

SNOMED

128277003 | Cellulitis of head (disorder) |37223007 | Cellulitis of neck (disorder) |46876003 | Cellulitis of trunk (disorder) |449671007 | Cellulitis of upper limb (disorder) |449710006 | Cellulitis of lower limb (disorder) |26330000 | Cellulitis of perineum (disorder)

C0007642, Cellulitis

clinical_features

1

1

outcome

COMPLICATIONS: Experienced at any time from day of presentation to day of discharge / outcome.

compl_cellulitis_site_oth

text

Specify other site(s) of cellulitis

[compl_cellulitis_site(88)]=’1’

Skin

This refers to the other site(s) in which cellulitis was identified.

If ‘Other’, write the site(s) in which cellulitis was identified at any time during hospitalisation.

clinical_features

1

1

outcome

COMPLICATIONS: Experienced at any time from day of presentation to day of discharge / outcome.

compl_skabscess

radio

Skin abscess

1, Yes | 0, No | 99, Unknown

Skin

This refers to a circumscribed area of pus or necrotic debris in the skin.

Indicate ‘Yes’, if the patient experienced this at any time during hospitalisation.

1

outcome

COMPLICATIONS: Experienced at any time from day of presentation to day of discharge / outcome.

compl_eschar

radio

Skin tissue loss or eschar

1, Yes | 0, No | 99, Unknown

Skin

Eschar is defined as a dry, dark scab or falling away of dead skin, typically caused by a burn, an insect bite (e.g. some rickettsial infections), or infection with anthrax.

Indicate ‘Yes’, if the patient experienced this at any time during hospitalisation.

SNOMED

409590008, Skin eschar

C0521172, Skin eschar

clinical_features

1

1

outcome

COMPLICATIONS: Experienced at any time from day of presentation to day of discharge / outcome.

compl_scar

radio

Skin scarring

1, Yes | 0, No | 99, Unknown

Skin

This refers to a permanent mark left on the skin in the process of wound healing.

Indicate ‘Yes’, if the patient experienced this at any time during hospitalisation.

1

outcome

COMPLICATIONS: Experienced at any time from day of presentation to day of discharge / outcome.

compl_nec

radio

Necrotising infection

1, Yes | 0, No | 99, Unknown

Skin

This refers to infection associated with death of skin and underlying soft tissue.

Indicate ‘Yes’, if the patient experienced this at any time during hospitalisation.

1

1

outcome

COMPLICATIONS: Experienced at any time from day of presentation to day of discharge / outcome.

compl_eye

descriptive

Opthalmological complication

Ocular

Defined as any complications of the eye

Indicate ‘Yes’, if the patient experienced this at any time during hospitalisation.

1

outcome

COMPLICATIONS: Experienced at any time from day of presentation to day of discharge / outcome.

compl_eyeinf

radio

Ocular infection

1, Yes | 0, No | 99, Unknown

Ocular

This refers to an infectious process affecting any part of the eye.

Indicate ‘Yes’, if the patient experienced this at any time during hospitalisation.

1

outcome

COMPLICATIONS: Experienced at any time from day of presentation to day of discharge / outcome.

compl_cornealsubepi

radio

Corneal subethelial infiltrates

1, Yes | 0, No | 99, Unknown

Ocular

This refers to subepithelial corneal infiltrates.

Indicate ‘Yes’, if the patient experienced this at any time during hospitalisation.

1

outcome

COMPLICATIONS: Experienced at any time from day of presentation to day of discharge / outcome.

compl_cornealstroma

radio

Corneal stromal infiltrates

1, Yes | 0, No | 99, Unknown

Ocular

This refers to stromal corneal infiltrates.

Indicate ‘Yes’, if the patient experienced this at any time during hospitalisation.

1

outcome

COMPLICATIONS: Experienced at any time from day of presentation to day of discharge / outcome.

compl_sys

descriptive

Systemic complication

Systemic/General

Defined as any systemic complications

Indicate ‘Yes’, if the patient experienced this at any time during hospitalisation.

1

1

1

1

1

1

1

1

outcome

COMPLICATIONS: Experienced at any time from day of presentation to day of discharge / outcome.

compl_bacteraemi

radio

Bacteraemia

1, Yes | 0, No | 99, Unknown

Systemic/General

Defined as the presence of bacteria in blood, most often detected through blood culture investigation. Episodes of suspected artefactual contamination of a blood culture should not be recorded.

Indicate ‘Yes’ if bacteraemia occurred at any time during hospitalisation. Indicate ‘No’, if bacteraemia never occurred or if only bacteria grown were believed to be skin contaminants (e.g. coagulase negative Staphylococci or diphtheroids).

SNOMED

5758002, Bacteremia

C0004610, Bacteremia

clinical_features

1

1

1

1

1

1

outcome

COMPLICATIONS: Experienced at any time from day of presentation to day of discharge / outcome.

compl_hyperglyce

radio

Hyperglycemia

1, Yes | 0, No | 99, Unknown

Systemic/General

For adults, is defined as an abnormally high level of glucose in the blood, blood glucose level that is consistently above 126mg/dL or 7 mmol/L. For children, is defined as a blood glucose level consistently above 8.3 mmol/L.

Indicate ‘Yes’ if bacteraemia occurred at any time during hospitalisation. Indicate ‘No’, if bacteraemia never occurred or if only bacteria grown were believed to be skin contaminants (e.g. coagulase negative Staphylococci or diphtheroids).

SNOMED

80394007, Hyperglycaemia

C4015534, Hyperglycaemia

clinical_features

1

1

1

outcome

COMPLICATIONS: Experienced at any time from day of presentation to day of discharge / outcome.

compl_hypoglycem

radio

Hypoglycaemia

1, Yes | 0, No | 99, Unknown

Systemic/General

This refers to abnormally low level of glucose in the blood. For adults, is defined as an abnormally low level of glucose in the blood, a blood glucose level that is consistently below 70mg/dL or 4 mmol/L. For children, is defined as a blood glucose level below 3 mmol/L.

Indicate ‘Yes’, if the patient experienced this at any time during hospitalisation.

SNOMED

302866003, Hypoglycaemia

C0858246, Hypoglycaemia

clinical_features

1

1

1

1

outcome

COMPLICATIONS: Experienced at any time from day of presentation to day of discharge / outcome.

compl_shock

radio

Shock

1, Yes | 0, No | 99, Unknown

Systemic/General

Shock refers to circulatory failure, causing inadequate oxygen delivery to meet cellular metabolic needs. It is defined by the presence of any two of the following: evidence of hypoperfusion (e.g. capillary refill >2 seconds, cold clammy skin, and rapid/weak pulse, altered mental status), narrow pulse pressure (less than or equal to 20mmHg), hypotension for age, and tachycardia (>100bpm).

Indicate ‘Yes’, if the patient experienced this at any time during hospitalisation.

SNOMED

27942005, Shock

C0036974, Shock

clinical_features

1

1

1

1

outcome

COMPLICATIONS: Experienced at any time from day of presentation to day of discharge / outcome.

compl_reshock

radio

Re-shock episodes

1, Yes | 0, No | 99, Unknown

Systemic/General

Re-shock or recurrent shock is defined as a separate episode of shock which occurs at least 2-6 hours after the clinical resolution of an initial episode of shock, where clinical resolution refers to a pulse pressure >25mmHg without signs of impaired perfusion. This does not include persistent shock (where no resolution is seen).

Indicate ‘Yes’, if the patient experienced this at any time during hospitalisation.

clinical_features

1

1

outcome

COMPLICATIONS: Experienced at any time from day of presentation to day of discharge / outcome.

compl_reshockep

radio

Number of re-shock episodes

1, 1 | 2, 2 | 3, 3 | 4, 4+ | 99, Unknown

[compl_reshock]=’1’

Systemic/General

This refers to the number of times re-shock was identified while the patient was hospitalised.

If ‘Yes’, select the single most appropriate option which corresponds to the number of re-shock episodes the patient has experienced at any time during hospitalisation.

clinical_features

1

1

outcome

COMPLICATIONS: Experienced at any time from day of presentation to day of discharge / outcome.

compl_sepsis

radio

Sepsis

1, Yes | 0, No | 99, Unknown

Systemic/General

As defined according to the 2016 SCCM/ESICM task force as a life-threatening organ dysfunction caused by a dysregulated host response to infection with the following: Organ dysfunction determined by a Sequential Organ Failure Assessment (SOFA) score of greater or equal to 2 points (or quick SOFA/qSOFA score of greater or equal to 2); and a Physician-diagnosed infection (which can be supported by clinical signs and symptoms, radiologic and/or microbiologic evidence).

Indicate ‘Yes’, if the patient experienced this at any time during hospitalisation.

SNOMED

91302008, Sepsis

C0243026, Sepsis

clinical_features

1

1

1

1

1

outcome

COMPLICATIONS: Experienced at any time from day of presentation to day of discharge / outcome.

compl_hypothermia

radio

Hypothermia

1, Yes | 0, No | 99, Unknown

Systemic/General

This refers to abnormally low body temperature.

Indicate ‘Yes’, if the patient experienced this at any time during hospitalisation.

1

outcome

COMPLICATIONS: Experienced at any time from day of presentation to day of discharge / outcome.

compl_ndiab

radio

New-onset diabetes mellitus

1, Yes | 0, No | 99, Unknown

1

outcome

COMPLICATIONS: Experienced at any time from day of presentation to day of discharge / outcome.

compl_plarthalgia

radio

Polyartralgia

1, Yes | 0, No | 99, Unknown

1

outcome

COMPLICATIONS: Experienced at any time from day of presentation to day of discharge / outcome.

compl_otherdesc

descriptive

Other Complications

Other

1

1

1

1

1

1

1

1

1

outcome

COMPLICATIONS: Experienced at any time from day of presentation to day of discharge / outcome.

compl_unlisted

list

Other complication(s)

1, Yes | 0, No | 99, Unknown

conditions_Complications

Other

This refers to other complication(s) not specified above.

Specify all other complication(s), not listed above, the patient experienced at any time during hospitalisation.

clinical_features

1

1

1

1

1

1

1

1

1

outcome

INTERVENTIONS: Record interventions given or prescribed from day of presentation to day of discharge / outcome.

inter_ivfluid

radio

Intravenous (parenteral) fluids

1, Yes | 0, No | 99, Unknown

This refers to intravenous fluid which includes crystalloid, albumin, gelatin, starches or other solutions.

Indicate ‘Yes’, if the patient received intravenous fluids at any time during hospitalisation.

1

1

outcome

INTERVENTIONS: Record interventions given or prescribed from day of presentation to day of discharge / outcome.

inter_ivfluid_type

user_list

Intravenous fluid type

drugs_IVfluids

[inter_ivfluid]=’1’

This refers to the type of parenteral or intravenous (IV) fluid is prescribed as a replacement of fluid, electrolytes, calories, vitamins, and other nutritional substances. Intravenous fluids may be crystalloids (commonly including 0.9% Sodium Chloride (Normal Saline), Lactated Ringer(USP), 0.45% Sodium Chloride (Half-normal saline), 0.45% normal saline + 4% Glucose (Half-normal saline with dextrose), 0.18%-0.3% Sodium Chloride + 4% Glucose (Hypotonic saline with dextrose), 5% Glucose (Dextrose 5% in Water), Ringeracetate or Plasmalyte) or colloids (commonly including gelatins, starches or albumin).

Select the most appropriate option corresponding to the type of intravenous or parenteral fluid(s) administered.

1

1

1

outcome

INTERVENTIONS: Record interventions given or prescribed from day of presentation to day of discharge / outcome.

inter_ivfluid_cryst

number

Total crystalloid volume given during admission (mL)

number

0

[inter_ivfluid]=’1’

Crystalloid fluids refer to aqueous solutions of mineral salts and other small, water-soluble molecules. They are commonly used for fluid resuscitation in the presence of hypovolemia, hemorrhage, sepsis, and dehydration Common crystalloids include 0.9% Sodium Chloride (Normal Saline), Lactated Ringer(USP), 0.45% Sodium Chloride (Half-normal saline), 0.45% normal saline + 4% Glucose (Half-normal saline with dextrose), 0.18%-0.3% Sodium Chloride + 4% Glucose (Hypotonic saline with dextrose), 5% Glucose (Dextrose 5% in Water), Ringeracetate or Plasmalyte.

Record the total volume of crystalloid fluids the patient received during admission in millilitres (mL).

1

1

outcome

INTERVENTIONS: Record interventions given or prescribed from day of presentation to day of discharge / outcome.

inter_ivfluid_colloid

number

Total colloid volume given during admission (mL)

number

0

[inter_ivfluid]=’1’

Colloid fluids are solutions that contain large molecules, such as proteins or polysaccharides, which remain in the bloodstream for a longer duration compared to crystalloids. These fluids help maintain or expand intravascular volume by drawing water into the blood vessels via oncotic pressure. Common colloids include gelatins, starches or albumin.

Record the total volume of colloid fluid the patient received during admission in millilitres (mL).

1

1

outcome

INTERVENTIONS: Record interventions given or prescribed from day of presentation to day of discharge / outcome.

inter_ivfluid_reas

checkbox

Reason(s) for IV fluid (check all that apply)

1, Shock | 2, High/rising haematocrit | 3, Anorexia | 4, Persistent vomiting | 88, Other

[inter_ivfluid] =’1’

This refers to the reason(s) (indication(s)) for parenteral / intravenous (IV) fluid therapy at any time during the admission. If multiple indications, select all that apply. Shock refers to circulatory failure, causing inadequate oxygen delivery to meet cellular metabolic needs. It is defined by the presence of any two of the following: evidence of hypoperfusion (e.g. capillary refill >2 seconds, cold clammy skin, and rapid/weak pulse, altered mental status), narrow pulse pressure (less than or equal to 20mmHg), hypotension for age, and tachycardia (>100bpm). High/rising haematorit refers to an elevation above the normal ratio of the volume of red blood cells to the total volume of blood. Anorexia refers to the lack or loss of appetite accompanied by an aversion to food and the inability to eat.

Select all that apply.

SNOMED

27942005, Shock | 165413005, Haematocrit above reference range (finding) | 79890006, Loss of appetite (finding) | 196746003, Persistent vomiting (disorder)

1

1

outcome

INTERVENTIONS: Record interventions given or prescribed from day of presentation to day of discharge / outcome.

inter_ivfluid_reas_oth

text

Specify other reason for IV fluid

[inter_ivfluid_reas(88)]=’1’

This refers to the reason(s) (indication(s)) for parenteral / intravenous (IV) fluid therapy at any time during the admission.

If ‘Other’, specify the reason(s) (indication(s)) for parenteral / intravenous (IV) fluid therapy at any time during the admission.

1

1

outcome

INTERVENTIONS: Record interventions given or prescribed from day of presentation to day of discharge / outcome.

inter_ivfluid_start

datetime_dmy

Date first IV fluid started

datetime_dmy

today

[inter_ivfluid] =’1’

This refers to the date when the first parenteral / intravenous (IV) fluid was started.

Enter the date. (Use the format DD/MM/YYYY)

1

1

outcome

INTERVENTIONS: Record interventions given or prescribed from day of presentation to day of discharge / outcome.

inter_ivfluid_end

datetime_dmy

Date last IV fluid ended

datetime_dmy

[inter_ivfluid] =’1’

This refers to the date when the last parenteral / intravenous (IV) fluid was ended.

Enter the date. (Use the format DD/MM/YYYY)

1

1

outcome

INTERVENTIONS: Record interventions given or prescribed from day of presentation to day of discharge / outcome.

inter_bpt

radio

Blood product transfusion

1, Yes | 0, No | 99, Unknown

This refers to a transfusion of blood (whole blood or packed red blood cells) or other blood products excluding human normal immunoglobulin (e.g. albumin, granulocytes, platelets, fresh-frozen plasma (FFP), FP24, PF-24, cryoprecipitate, protein C concentrate, cryosupernatant, or a specific non-recombinant clotting factor) at any time on the date of assessment.

Indicate ‘Yes’, if the patient received blood products or blood product transfusion at any time during admission. If ‘Yes’ Select the product(s) below.

SNOMED

116859006, Transfusion of blood product (procedure) |

1

outcome

INTERVENTIONS: Record interventions given or prescribed from day of presentation to day of discharge / outcome.

inter_bpt_type

checkbox

Select all blood product transfusion that were administered

1, Platelets | 2, Cryoprecipitate | 3, Whole blood | 4, Frozen fresh plasma | 5, Fibrinogen concentrate | 6, Packed RBC (red cell concentrate)

[inter_bpt] =’1’

This refers to a transfusion of blood (whole blood or packed red blood cells) or other blood products excluding human normal immunoglobulin (e.g. albumin, granulocytes, platelets, fresh-frozen plasma (FFP), FP24, PF-24, cryoprecipitate, protein C concentrate, cryosupernatant, or a specific non-recombinant clotting factor) at any time on the date of assessment. Platelets refers to the transfer of blood platelets from a donor to a recipient or reinfusion to the donor. Cryoprecipitate refers to a frozen blood product prepared from frozen plasma that contains fibrinogen (factor I), antihemophilic factor (factor VIII), factor XIII, von Willebrand factor (vWF) and fibronectin. Whole blood refers to intravenous administration of whole blood (blood that contains plasma and red blood cells) into an individual. Packed RBC refers to red blood cells from a unit of whole blood following removal of most of the plasma, leaving a unit with a haematocrit of about 60%. Fresh frozen plasma refers to the plasma that is separated from the whole blood and frozen quickly after a blood donation in order to be used for blood transfusions. Fibrinogen concentrate is a haemostatic agent used for the treatment of acute bleeding episodes in patients with congenital fibrinogen deficiency, including afibrinogenemia and hypofibrinogenemia.

Select the most appropriate option(s) corresponding to the blood product(s) that were administered.

SNOMED

12719002, Platelet transfusion (procedure) | 116795008, Transfusion of cryoprecipitate (procedure) | 180207008, Intravenous blood transfusion of packed cells (procedure) | 116861002, Transfusion of fresh frozen plasma (procedure) | 776201000, Product containing only human fibrinogen (medicinal product) |

1

outcome

INTERVENTIONS: Record interventions given or prescribed from day of presentation to day of discharge / outcome.

inter_bpt_plate

number

Platelets, total number of units

number

0

200

[inter_bpt_type(1)] = ‘1’

Platelets refers to the transfer of blood platelets from a donor to a recipient or reinfusion to the donor.

Record the total number of units the patient received during admission.

SNOMED

12719002, Platelet transfusion (procedure)

1

outcome

INTERVENTIONS: Record interventions given or prescribed from day of presentation to day of discharge / outcome.

inter_bpt_cryo

number

Cryoprecipitate, total number of units

number

0

200

[inter_bpt_type(2)]=’1’

Cryoprecipitate refers to a frozen blood product prepared from frozen plasma that contains fibrinogen (factor I), antihemophilic factor (factor VIII), factor XIII, von Willebrand factor (vWF) and fibronectin. Cryoprecipitate refers to a frozen blood product prepared from frozen plasma that contains fibrinogen (factor I), antihemophilic factor (factor VIII), factor XIII, von Willebrand factor (vWF) and fibronectin.

Record the total number of units the patient received during admission.

SNOMED

116795008, Transfusion of cryoprecipitate (procedure)

1

outcome

INTERVENTIONS: Record interventions given or prescribed from day of presentation to day of discharge / outcome.

inter_bpt_rbc

number

Whole blood, total number of units

number

0

100

[inter_bpt_type(3)]=’1’

Whole blood refers to intravenous administration of whole blood (blood that contains plasma and red blood cells) into an individual.

Record the total number of units the patient received during admission.

SNOMED

180207008, Intravenous blood transfusion of packed cells (procedure

1

outcome

INTERVENTIONS: Record interventions given or prescribed from day of presentation to day of discharge / outcome.

inter_bpt_ffp

number

Fresh frozen plasma (FFP), total number of units

number

0

200

[inter_bpt_type(4)]=’1’

Fresh frozen plasma refers to the plasma that is separated from the whole blood and frozen quickly after a blood donation in order to be used for blood transfusions.

Record the total number of units the patient received during admission.

SNOMED

116861002, Transfusion of fresh frozen plasma (procedure)

1

outcome

INTERVENTIONS: Record interventions given or prescribed from day of presentation to day of discharge / outcome.

inter_bpt_fibrin

number

Fibrinogen concentrate, total number of units

number

0

100

[inter_bpt_type(5)]=’1’

Fibrinogen concentrate is a hemostatic agent used for the treatment of acute bleeding episodes in patients with congenital fibrinogen deficiency, including afibrinogenemia and hypofibrinogenemia.

Record the total number of units the patient received during admission.

SNOMED

776201000, Product containing only human fibrinogen (medicinal product)

1

outcome

INTERVENTIONS: Record interventions given or prescribed from day of presentation to day of discharge / outcome.

inter_bpt_rcc

number

Packed RBC (red cell concentrate), total number of units

number

0

200

[inter_bpt_type(6)]=’1’

Packed RBC refers to red blood cells from a unit of whole blood following removal of most of the plasma, leaving a unit with a haematocrit of about 60%.

Record the total number of units the patient received during admission.

SNOMED

1

outcome

INTERVENTIONS: Record interventions given or prescribed from day of presentation to day of discharge / outcome.

inter_ivimmunogl

radio

Intravenous immunoglobulin

1, Yes | 0, No | 99, Unknown

This refers to immunoglobulin preparations, containing primarily Immunoglobulin G (IgG), that are used as intravenous infusions. Examples include Octagam®, Intragam P®, KIOVIG®, Flebogamma 5% DIF®, Carimune NF®, Gamunex®, Gammagard S/D®, Gammagard Liquid®, Gammaked® and Privigen®.

Indicate ‘Yes’, if the patient received intravenous immunoglobulin at any time during admission.

SNOMED

698802001, Administration of immunoglobulin by intravenous route (procedure) |

1

1

outcome

INTERVENTIONS: Record interventions given or prescribed from day of presentation to day of discharge / outcome.

inter_diuretics

radio

Diuretics

1, Yes | 0, No | 99, Unknown

This refers to class of agents that increases the production of urine by the kidney. Via various mechanism of actions, diuretics retain water in urine, thus provides a means of forced diuresis.

Indicate ‘Yes’, if the patient received diuretic therapy at any time during admission.

SNOMED

30492008 | Medicinal product acting as diuretic (product) |

C0012798, Diuretic

1

1

outcome

INTERVENTIONS: Record interventions given or prescribed from day of presentation to day of discharge / outcome.

inter_nacetylcys

radio

N-acetyl cysteine

1, Yes | 0, No | 99, Unknown

This refers to N-acetyl derivative of cysteine; used as a mucolytic agent to reduce the viscosity of mucous secretions.

Indicate ‘Yes’, if the patient received N-acetyl cysteine (NAC) at any time during admission.

SNOMED

77731008, Product containing acetylcysteine (medicinal product)

C0001047, acetylcysteine

1

1

outcome

INTERVENTIONS: Record interventions given or prescribed from day of presentation to day of discharge / outcome.

inter_fluiddrain

radio

Fluid drainage

1, Yes | 0, No | 99, Unknown

This refers to the procedure of removing fluid from the pleural space or peritoneal cavity.

Indicate ‘Yes’, if this was fluid drainage from the pleural or peritoneal cavity was performed at any time during admission.

1

1

outcome

INTERVENTIONS: Record interventions given or prescribed from day of presentation to day of discharge / outcome.

inter_fluiddrain_reas

radio

Reason for this drainage

1, Ascites | 2, Pleural effusion

[inter_fluiddrain] = ‘1’

This refers to the reason (indication) for fluid drainage. Ascites refers to the abnormal accumulation of fluid in the peritoneal cavity. Pleural effusion refers to presence of fluid in the pleural cavity resulting from excessive transudation or exudation from the pleural surfaces.

Select the most appropriate option corresponding to the reason (indication) for fluid drainage.

SNOMED

389026000, Ascites (disorder) | 60046008, Pleural effusion (disorder)

1

1

outcome

INTERVENTIONS: Record interventions given or prescribed from day of presentation to day of discharge / outcome.

inter_plasmaex

radio

Plasmapheresis / plasma exchange

1, Yes | 0, No | 99, Unknown

Plasmapheresis (plasma exchange) refers to the extracorporeal separation of blood components, resulting in a filtered product. Methods include discontinuous flow centrifugation, continuous flow centrifugation and plasma filtration.

Indicate ‘Yes’, if the patient received plasmapharesis at any time during admission.

SNOMED

20720000, Plasmapheresis (procedure)

C0032134, Plasmapheresis

1

1

1

outcome

INTERVENTIONS: Record interventions given or prescribed from day of presentation to day of discharge / outcome.

inter_plasmaex_days

number

Days on plasma exchange support during admission

number

0

[inter_plasmaex] = ‘1’

This refers to the total number of calendar days the patient was on plasma exchange support (plasmapharesis). Plasmapheresis (plasma exchange) refers to the extracorporeal separation of blood components, resulting in a filtered product. Methods include discontinuous flow centrifugation, continuous flow centrifugation and plasma filtration.

Write the total number of calendar days the patient was on plasma exchange support (plasmapheresis).

1

1

1

outcome

INTERVENTIONS: Record interventions given or prescribed from day of presentation to day of discharge / outcome.

inter_isolation

radio

Was the patient isolated at home or in hospital?

1, Yes | 0, No | 99, Unknown

This refers to isolation of the patient at home or in hospital during this admission for pathogen of interest.

Indicate ‘Yes’ if the patient was isolation at home or in hospital during this admission for pathogen of interest.

1

1

outcome

INTERVENTIONS: Record interventions given or prescribed from day of presentation to day of discharge / outcome.

inter_isolation_date

date_dmy

Date individual entered isolation

date_dmy

today

[inter_isolation]=’1’

This refers to the start date of isolation of the patient at home or in hospital during this admission for pathogen of interest.

Enter the date. (Use the format DD/MM/YYYY)

1

1

outcome

INTERVENTIONS: Record interventions given or prescribed from day of presentation to day of discharge / outcome.

inter_surg

radio

Any surgical intervention performed in relation to the infection with pathogen of interest?

1, Yes | 0, No | 99, Unknown

This refers to any surgical intervention that was performed in relation to the infection with pathogen of interest.

Indicate ‘Yes’ if a surgical intervention was performed in relation to the infection with pathogen of interest.

1

1

1

outcome

INTERVENTIONS: Record interventions given or prescribed from day of presentation to day of discharge / outcome.

inter_surg_type

text

What was the surgery? (e.g. debridement of infected tissue)

[inter_surg]=’1’

This refers to any surgical intervention that was performed in relation to the infection with pathogen of interest.

If ‘Yes’, write the name of surgical intervention / procedure that was performed in relation to the infection with pathogen of interest.

1

1

1

outcome

INTERVENTIONS: Record interventions given or prescribed from day of presentation to day of discharge / outcome.

inter_surg_date

date_dmy

Date of first surgery

date_dmy

today

[inter_surg]=’1’

This refers to the date of the first surgical intervention that was performed in relation to the infection with pathogen of interest.

Enter the date of the first surgery. (Use the format DD/MM/YYYY)

1

1

1

outcome

INTERVENTIONS: Record interventions given or prescribed from day of presentation to day of discharge / outcome.

inter_surg_sec

radio

Was a second surgical intervention performed in relation to the infection with pathogen of interest?

1, Yes | 0, No | 99, Unknown

[inter_surg]=’1’

This refers to any surgical intervention that was performed in relation to the infection with pathogen of interest.

Indicate ‘Yes’ if a second surgical intervention was performed in relation to the infection with pathogen of interest.

1

1

1

outcome

INTERVENTIONS: Record interventions given or prescribed from day of presentation to day of discharge / outcome.

inter_surg_secdate

date_dmy

Date of second surgery

date_dmy

today

[inter_surg_sec]=’1’

This refers to the date of the second surgical intervention that was performed in relation to the infection with pathogen of interest.

Enter the date of the second surgery. (Use the format DD/MM/YYYY)

1

1

1

outcome

INTERVENTIONS: Record interventions given or prescribed from day of presentation to day of discharge / outcome.

inter_other

radio

Other intervention(s) or procedure(s)

1, Yes | 0, No | 99, Unknown

This refers to any other specific therapeutic intervention(s) or procedure(s) administered at any time during the admission, not otherwise characterised that you believe may be relevant.

Indicate ‘Yes’ if other intervention(s) or procedure(s) were used between 00:00 and 24:00 hours on day of assessment.

SNOMED

71388002, Procedure (procedure)

C0184661, Interventional procedure

1

1

1

1

1

outcome

INTERVENTIONS: Record interventions given or prescribed from day of presentation to day of discharge / outcome.

inter_other_spec

text

Please specify other intervention(s) or procedure(s)

[inter_other] = ‘1’

This refers to any other specific therapeutic intervention(s) or procedure(s) administered at any time during the admission, not otherwise characterised that you believe may be relevant.

If ‘Yes’, please specify the therapeutic intervention(s) or procedure(s)not otherwise characterised that you believe may be relevant.

SNOMED

71388002, Procedure (procedure)

C0184661, Interventional procedure

1

1

1

1

1

outcome

RESPIRATORY SUPPORT: Record all respiratory interventions given or prescribed from day of presentation to day of discharge / outcome.

inter_suppleo2

radio

Any supplemental oxygen?

1, Yes | 0, No | 99, Unknown

This refers to any method of supplemental oxygen therapy that may be delivered via nose cannula, mask or non-invasive or invasive ventilation.

Indicate ‘Yes’, if the patient experienced was given or prescribed supplemental oxygen therapy at any time during hospitalisation.

SNOMED

250774007, Inspired oxygen concentration (observable entity)|

C0428648, Inspired oxygen concentration

patient_outcome, clinical_features, treatment

1

1

1

1

1

1

1

outcome

RESPIRATORY SUPPORT: Record all respiratory interventions given or prescribed from day of presentation to day of discharge / outcome.

inter_suppleo2_ongoing

radio

Still on supplemental oxygen?

1, Yes | 0, No | 99, Unknown

[inter_suppleo2]=’1’

This refers to ongoing oxygen therapy that may be delivered via nose cannula, mask or non-invasive or invasive ventilation.

Indicate ‘Yes’, if the patient is still on supplemental oxygen therapy.

1

outcome

RESPIRATORY SUPPORT: Record all respiratory interventions given or prescribed from day of presentation to day of discharge / outcome.

inter_suppleo2_dur

number

Number of calendar days the patient received any respiratory support during admission

number

0

[inter_suppleo2]=’1’

This refers to the total number of calendar days the patient received this respiratory support during admission (includes use at any time during admission).

Write the total number of calendar days the patient received this respiratory support during admission (includes use at any time during admission).

clinical_features, treatment

1

1

1

1

1

1

1

outcome

RESPIRATORY SUPPORT: Record all respiratory interventions given or prescribed from day of presentation to day of discharge / outcome.

inter_suppleo2_flow

radio

Maximum O2 flow volume (L/min)

1, <2 L/min | 2, 2-5 L/min | 3, 6-10 L/min | 4, 11-15 L/min | 5, >15 L/min | 99, Unknown

[inter_suppleo2] = ‘1’

This refers to the maximum flow volume of O2 delivered to the patient at any time during hospitalisation.

Select the maximum flow volume of O2 delivered to the patient at any time during hospitalisation.

SNOMED

427081008, Delivered oxygen flow rate (observable entity)

C1960999, Delivered oxygen flow rate

clinical_features

1

1

1

1

1

1

1

outcome

RESPIRATORY SUPPORT: Record all respiratory interventions given or prescribed from day of presentation to day of discharge / outcome.

inter_nasalprongs

radio

Nasal prongs

1, Yes | 0, No | 99, Unknown

[inter_suppleo2]=’1’

This refers to the mode in which the patient received supplemental oxygen on day of assessment. Nasal prongs or nasal cannluae deliver oxygen through two small prongs or cannulae insterted into the nostrils.

Indicate ‘Yes’, if this mode of respiratory support was used to deliver supplemental oxygen at any time during hospitalisation

SNOMED

SNOMED

C0445087, Nasal prongs

1

1

1

1

1

1

outcome

RESPIRATORY SUPPORT: Record all respiratory interventions given or prescribed from day of presentation to day of discharge / outcome.

inter_nasalprongs_ongoing

radio

Still ongoing?

1, Yes | 0, No | 99, Unknown

[inter_nasalprongs]=’1’

This refers to ongoing non-invasive ventilation.

Indicate ‘Yes’, if the patient is still on supplemental oxygen through nasal prongs.

1

outcome

RESPIRATORY SUPPORT: Record all respiratory interventions given or prescribed from day of presentation to day of discharge / outcome.

inter_nasalprongs_dur

number

Number of calendar days the patient received supplemental oxygen through nasal prongs

number

0

[inter_nasalprongs]=’1’

This refers to the total number of calendar days the patient received non-invasive ventilation.

Write the total number of calendar days the patient received supplemental oxygen through nasal prongs during admission (includes use at any time during admission).

1

1

1

1

1

outcome

RESPIRATORY SUPPORT: Record all respiratory interventions given or prescribed from day of presentation to day of discharge / outcome.

inter_facemask

radio

Face mask

1, Yes | 0, No | 99, Unknown

[inter_suppleo2]=’1’

This refers to the mode in which the patient received supplemental oxygen on day of assessment. A simple oxygen face mask is a device placed over a patient’s nose, mouth, or tracheostomy to administer oxygen to the airway.

Indicate ‘Yes’, if this mode of respiratory support was used to deliver supplemental oxygen at any time during hospitalisation

SNOMED

SNOMED

C1299377, Oxygen administration by mask

1

1

1

1

1

1

outcome

RESPIRATORY SUPPORT: Record all respiratory interventions given or prescribed from day of presentation to day of discharge / outcome.

inter_facemask_ongoing

radio

Still ongoing?

1, Yes | 0, No | 99, Unknown

[inter_facemask]=’1’

This refers to ongoing non-invasive ventilation.

Indicate ‘Yes’, if the patient is still on supplemental oxygen through face mask.

1

outcome

RESPIRATORY SUPPORT: Record all respiratory interventions given or prescribed from day of presentation to day of discharge / outcome.

inter_facemask_dur

number

Number of calendar days the patient received supplemental oxygen through face mask

number

0

[inter_facemask]=’1’

This refers to the total number of calendar days the patient received non-invasive ventilation.

Write the total number of calendar days the patient received supplemental oxygen through face mask during admission (includes use at any time during admission).

1

1

1

1

1

outcome

RESPIRATORY SUPPORT: Record all respiratory interventions given or prescribed from day of presentation to day of discharge / outcome.

inter_hfno

radio

High flow nasal oxygen

1, Yes | 0, No | 99, Unknown

[inter_suppleo2]=’1’

This refers to the mode in which the patient received supplemental oxygen on day of assessment. High -flow nasal oxygen therapy is a non-invasive respiratory support that delivers warmed, humidified, oxygen-enriched air to patients through a high-flow nasal cannula at flow rates greater than those typically delivered by standard-flow oxygen devices.

Indicate ‘Yes’, if this mode of respiratory support was used to deliver supplemental oxygen to the patient at any time during hospitalisation.

SNOMED

SNOMED

C4761117, High-flow nasal cannula oxygen therapy

1

1

1

1

1

1

outcome

RESPIRATORY SUPPORT: Record all respiratory interventions given or prescribed from day of presentation to day of discharge / outcome.

inter_hfno_ongoing

radio

Still ongoing?

1, Yes | 0, No | 99, Unknown

[inter_hfno]=’1’

This refers to ongoing non-invasive ventilation.

Indicate ‘Yes’, if the patient is still on high-flow nasal oxygen.

1

outcome

RESPIRATORY SUPPORT: Record all respiratory interventions given or prescribed from day of presentation to day of discharge / outcome.

inter_hfno_dur

number

Number of calendar days the patient received high-flow nasal oxygen

number

0

[inter_hfno]=’1’

This refers to the total number of calendar days the patient received high-flow nasal oxygen.

Write the total number of calendar days the patient received high-flow nasal oxygen during admission (includes use at any time during admission).

1

1

1

1

1

outcome

RESPIRATORY SUPPORT: Record all respiratory interventions given or prescribed from day of presentation to day of discharge / outcome.

inter_nivent

radio

Non-invasive ventilation

1, Yes | 0, No | 99, Unknown

[inter_suppleo2]=’1’

This refers to the mode in which the patient received supplemental oxygen on day of assessment. Non-invasive ventilation refers to the provision of ventilatory support through the patient’s upper airway using a mask or similar device, without the need for tracheal intubation. Examples include Continuous Positive Airway Pressure (CPAP) and Biphasic Continuous Positive Airway Pressure (BiPAP).

Indicate ‘Yes’, if this mode of respiratory support was used to deliver supplemental oxygen at any time during hospitalisation

SNOMED

SNOMED

C1997883, Noninvasive Ventilation

1

1

1

1

1

1

1

outcome

RESPIRATORY SUPPORT: Record all respiratory interventions given or prescribed from day of presentation to day of discharge / outcome.

inter_nivent_type

radio

Type of non-invasive respiratory support

1, CPAP | 2, BIPAP | 99, Unknown | 88, Other

[inter_nivent]=’1’

Non-invasive respiratory support or ventilation (NIV) refers to the provision of ventilatory support through the patient’s upper airway using a mask or similar device. It includes high-flow nasal cannula, continuous positive airway pressure (CPAP) and bilevel positive airway pressure (BPAP).

Select the single most appropriate option corresponding to the type of NIV used at any time during hospitalisation

SNOMED

SNOMED

C0199451, Continuous Positive Airway Pressure | C0419004, Dual pressure spontaneous ventilation support’

1

1

1

1

1

1

1

outcome

RESPIRATORY SUPPORT: Record all respiratory interventions given or prescribed from day of presentation to day of discharge / outcome.

inter_nivent_typ_oth

text

Specify other type of non-invasive ventilation

[inter_nivent_type]=’88’

Non-invasive respiratory support or ventilation (NIV) refers to the provision of ventilatory support through the patient’s upper airway using a mask or similar device. It includes high-flow nasal cannula, continuous positive airway pressure (CPAP) and bilevel positive airway pressure (BPAP).

If ‘Other’, specify other type of non-invasive ventilation.

1

1

1

1

1

1

outcome

RESPIRATORY SUPPORT: Record all respiratory interventions given or prescribed from day of presentation to day of discharge / outcome.

inter_nivent_ongoing

radio

Still ongoing?

1, Yes | 0, No | 99, Unknown

[inter_nivent]=’1’

This refers to ongoing non-invasive ventilation.

Indicate ‘Yes’, if the patient is still on non-invasive ventilation.

1

outcome

RESPIRATORY SUPPORT: Record all respiratory interventions given or prescribed from day of presentation to day of discharge / outcome.

inter_nivent_dur

number

Number of calendar days the patient received non-invasive ventilation

number

0

[inter_nivent]=’1’

This refers to the total number of calendar days the patient received non-invasive ventilation.

Write the total number of calendar days the patient received non-invasive ventilation during admission (includes use at any time during admission).

1

1

1

1

1

1

outcome

RESPIRATORY SUPPORT: Record all respiratory interventions given or prescribed from day of presentation to day of discharge / outcome.

inter_invent

radio

Invasive ventilation

1, Yes | 0, No | 99, Unknown

[inter_suppleo2]=’1’

This refers to the mode in which the patient received supplemental oxygen on day of assessment. Invasive ventilation indicates that patient has undergone tracheal intubation, for the purpose of invasive mechanical ventilation. Invasive mechanical ventilation (IMV) is a method to mechanically assist or replace spontaneous breathing in patients by use of a powered device that forces oxygenated air into the lungs. The mode of intubation may be orotracheal, nasotracheal, or via a cricothyrotomy or tracheotomy.

Indicate ‘Yes’, if this mode of respiratory support was used to deliver supplemental oxygen to the patient at any time during hospitalisation

SNOMED

SNOMED

C1868981, Invasive mechanical ventilation

1

1

1

1

1

1

1

outcome

RESPIRATORY SUPPORT: Record all respiratory interventions given or prescribed from day of presentation to day of discharge / outcome.

inter_invent_ongoing

radio

Still ongoing?

1, Yes | 0, No | 99, Unknown

[inter_invent]=’1’

This refers to ongoing invasive ventilation.

Indicate ‘Yes’, if the patient is still on invasive ventilation.

1

1

outcome

RESPIRATORY SUPPORT: Record all respiratory interventions given or prescribed from day of presentation to day of discharge / outcome.

inter_invent_dur

number

Number of calendar days the patient received invasive ventilation

number

0

[inter_invent]=’1’

This refers to the total number of calendar days the patient received invasive ventilation.

Write the total number of calendar days the patient received invasive ventilation during admission (includes use at any time during admission).

1

1

1

1

1

1

outcome

RESPIRATORY SUPPORT: Record all respiratory interventions given or prescribed from day of presentation to day of discharge / outcome.

inter_ecmo

radio

ECLS / ECMO

1, Yes | 0, No | 99, Unknown

[inter_suppleo2]=’1’

This refers to the mode in which the patient received supplemental oxygen on day of assessment. Extracorporeal Membrane Oxygenation (ECMO) also called to as Extracorporeal life support (ECLS) refers to application of a life support system that circulates the blood through an oxygenating system, which may consist of a pump, a membrane oxygenator, and a heat exchanger.

Indicate ‘Yes’, if this mode of respiratory support was used to deliver supplemental oxygen to the patient at any time during hospitalisation

SNOMED

SNOMED

C0015357, Extracorporeal Membrane Oxygenation

1

1

1

1

1

1

outcome

RESPIRATORY SUPPORT: Record all respiratory interventions given or prescribed from day of presentation to day of discharge / outcome.

inter_ecmo_typ

radio

Type of ECLS / ECMO

1, Veno-venous (VV) | 2, Veno-arterial (VA) | 99, Unknown

[inter_ecmo]=’1’

The two main types of Extracorporeal Membrane Oxygenation (ECMO), also called Extracorporeal life support (ECLS), are veno-venous (venous-venous), which is used to support the lungs and veno-arterial (venous-arterial), which is used to support the lungs and heart.

Select the single most appropriate option corresponding to the type of ECLS / ECMO used at any time during hospitalisation.

SNOMED

SNOMED

C5192099, Venovenous ECMO | C5192097, Venoarterial ECMO

1

1

1

1

1

1

outcome

RESPIRATORY SUPPORT: Record all respiratory interventions given or prescribed from day of presentation to day of discharge / outcome.

inter_ecmo_ongoing

radio

Still ongoing?

1, Yes | 0, No | 99, Unknown

[inter_ecmo]=’1’

This refers to ongoing ECMO/ECLS.

Indicate ‘Yes’, if the patient is still on ECMO/ECLS.

1

outcome

RESPIRATORY SUPPORT: Record all respiratory interventions given or prescribed from day of presentation to day of discharge / outcome.

inter_ecmo_dur

number

Number of calendar days the patient received ECLS / ECMO

number

0

[inter_ecmo]=’1’

This refers to the number of calendar days the patient received Extracorporeal Membrane Oxygenation (ECMO), also called Extracorporeal life support (ECLS).

Write the total number of calendar days the patient received ECLS/ECMO during admission (includes use at any time during admission).

1

1

1

1

1

outcome

RESPIRATORY SUPPORT: Record all respiratory interventions given or prescribed from day of presentation to day of discharge / outcome.

inter_prone

radio

Prone positioning

1, Yes | 0, No | 99, Unknown

[inter_suppleo2]=’1’

Prone positioning refers to the act of having the patient lying in the prone position to assist ventilation. This includes both invasive ventilation/intubated patients and non-intubated or self-ventilating patients.

Indicate ‘Yes’, for any patients if they have been in the prone position to aid their ventilation at any time during admission.

SNOMED

431182000 | Placing subject in prone position (procedure) |

CL1407586, Prone ventilation

1

1

1

1

1

outcome

RESPIRATORY SUPPORT: Record all respiratory interventions given or prescribed from day of presentation to day of discharge / outcome.

inter_prone_when

radio

When was the prone positioning?

1, During invasive ventilation | 2, Whilst self-ventilating | 99, Unknown

[inter_prone] = ‘1’

This refers to the type of assisted ventilation when the patient was placed in prone position. This may be either invasive ventilation / intubated patients or non-intubated / self-ventilating patients.

Specify the type of assisted ventilation administered when the patient was placed in prone position.

SNOMED

SNOMED

CL1407586, Prone ventilation

1

1

1

1

outcome

RESPIRATORY SUPPORT: Record all respiratory interventions given or prescribed from day of presentation to day of discharge / outcome.

inter_prone_awake

radio

Awake proning?

1, Yes | 0, No | 99, Unknown

[inter_prone] = ‘1’

This refers to the practice of proning patients while awake, without sedation, to improve oxygenation.

Indicate ‘Yes’, if awake proning was used at any time during admission.

1

outcome

RESPIRATORY SUPPORT: Record all respiratory interventions given or prescribed from day of presentation to day of discharge / outcome.

inter_othersuppleo2

radio

Other respiratory support intervention(s) or procedure(s)

1, Yes | 0, No | 99, Unknown

[inter_suppleo2]=’1’

This refers to any other specific respiratory support intervention(s) or procedure(s) not otherwise characterised that you believe may be relevant.

Indicate ‘Yes’ if other respiratory support intervention(s) or procedure(s) were used at any time during hospitalisation

SNOMED

SNOMED

C0184661, Interventional procedure

1

1

1

1

1

1

outcome

RESPIRATORY SUPPORT: Record all respiratory interventions given or prescribed from day of presentation to day of discharge / outcome.

inter_othersuppleo2_spec

text

Please specify other respiratory support intervention(s) or procedure(s)

[inter_othersuppleo2] = ‘1’

This refers to any other specific respiratory support intervention(s) or procedure(s) not otherwise characterised that you believe may be relevant.

If ‘Yes’, please specify the respiratory support intervention(s) or procedure(s) not otherwise characterised that you believe may be relevant.

SNOMED

SNOMED

C0184661, Interventional procedure

1

1

1

1

1

1

outcome

ADVANCED CARE INTERVENTIONS: Record all advanced care interventions given from day of presentation to day of discharge / outcome.

crito_critcare

radio

Were advanced care (including acute organ support and critical care) therapeutic interventions administered during this admission?

1, Yes | 0, No | 99, Unknown

This refers to any advanced care (including acute organ support and critical care) therapeutic intervention(s) or procedure(s) that were administered at any time during hospitalisation. This section does not include respiratory organ support interventions, which are recorded separately in another section.

Indicate ‘Yes’, if any advanced care (including acute organ support and critical care) therapeutic intervention(s) or procedure(s) were administered at any time during hospitalisation.

1

1

1

1

1

1

1

1

outcome

ADVANCED CARE INTERVENTIONS: Record all advanced care interventions given from day of presentation to day of discharge / outcome.

crito_icu

radio

ICU / ITU / HDU / Intermediate Care Unit admission

1, Yes | 0, No | 99, Unknown

[crito_critcare]=’1’

This refers to intensive care units (ICU), intensive therapy/treatment units (ITU), critical care units, high dependency units (HDU) or unit of similar level.

Indicate ‘Yes’ if the patient was admitted to ICU (or unit of similar level) at least once at any time during their hospitalisation.

patient_outcome, treatment

1

1

1

1

1

1

1

1

outcome

ADVANCED CARE INTERVENTIONS: Record all advanced care interventions given from day of presentation to day of discharge / outcome.

crito_icu_ongoing

radio

Still in ICU / ITU / HDU / Intermediate Care Unit?

1, Yes | 0, No | 99, Unknown

[crito_icu] = ‘1’

This refers to ongoing admission in the ICU / ITU / HDU / Intermediate Care Unit.

Indicate ‘Yes’ if the patient is stll admitted to ICU (or unit of similar level) .

1

1

outcome

ADVANCED CARE INTERVENTIONS: Record all advanced care interventions given from day of presentation to day of discharge / outcome.

crito_icu_date

date_dmy

Date of first ICU / ITU / HDU / Intermediate Care Unit admission

date_dmy

today

[crito_icu] = ‘1’

This refers to the date of first admission to the ICU (or unit of similar level).

Enter the date of the first admission to the ICU (or unit of similar level). (Use the format DD/MM/YYYY)

treatment

1

1

1

1

1

1

1

1

outcome

ADVANCED CARE INTERVENTIONS: Record all advanced care interventions given from day of presentation to day of discharge / outcome.

crito_icu_disdate

date_dmy

Date of first ICU discharge

date_dmy

today

[crito_icu] = ‘1’

This refers to the date of first discharge from the ICU (or unit of similar level).

Enter the date of the first discharge from the ICU (or unit of similar level). (Use the format DD/MM/YYYY)

1

1

1

1

1

outcome

ADVANCED CARE INTERVENTIONS: Record all advanced care interventions given from day of presentation to day of discharge / outcome.

crito_icu_dur

number

Duration of first ICU / ITU / HDU / Intermediate Care Unit admission (days)

number

0

[crito_icu] = ‘1’

This refers to the total duration of first admission to the ICU (or unit of similar level).

Write the total number of calendar days the patient was admitted to ICU.

1

1

1

1

1

1

1

1

outcome

ADVANCED CARE INTERVENTIONS: Record all advanced care interventions given from day of presentation to day of discharge / outcome.

crito_icu_readm

radio

Was the patient admitted to ICU / ITU / HDU / Intermediate Care Unit more than once?

1, Yes | 0, No | 99, Unknown

[crito_icu] = ‘1’

Refers to any admission to an intensive care unit (or unit of similar level) at any time during the patient’s admission.

Indicate ‘Yes’ if the patient was admitted to ICU more than once at any time during their hospitalisation.

treatment

1

1

1

1

1

outcome

ADVANCED CARE INTERVENTIONS: Record all advanced care interventions given from day of presentation to day of discharge / outcome.

crito_icu_findate

date_dmy

Date of final ICU / ITU / HDU / Intermediate Care Unit admission

date_dmy

today

[crito_icu_readm] = ‘1’

This refers to the date of first admission to the ICU (or unit of similar level).

Enter the date of the final admission to the ICU (or unit of similar level). (Use the format DD/MM/YYYY)

treatment

1

1

1

1

outcome

ADVANCED CARE INTERVENTIONS: Record all advanced care interventions given from day of presentation to day of discharge / outcome.

crito_icu_findur

number

Duration of final ICU / ITU / HDU / Intermediate Care Unit admission (days)

number

0

[crito_icu_readm] = ‘1’

This refers to the total duration of final admission to the ICU (or unit of similar level).

Write the total number of calendar days the patient was admitted to ICU.

treatment

1

1

1

1

1

outcome

ADVANCED CARE INTERVENTIONS: Record all advanced care interventions given from day of presentation to day of discharge / outcome.

crito_neuromuscu

radio

Neuromuscular blocking agents

1, Yes | 0, No | 99, Unknown

[crito_critcare]=’1’

This refers to the use of neuromuscular blockers at any time during the patient’s admission. Examples include Atracurium, Cisatracurium, Nimbex, Norcuron, Pancuronium, Pavulon, Rocuronium, Tracrium, Vecuronium, Zemuron.

Indicate ‘Yes’, if neuromuscular blockers were used any time during this admission.

SNOMED

87586001, Product containing neuromuscular blocker (product)

C0027866, Neuromuscular Blocking Agents

1

1

1

1

outcome

ADVANCED CARE INTERVENTIONS: Record all advanced care interventions given from day of presentation to day of discharge / outcome.

crito_nitricoxid

radio

Inhaled nitric oxide

1, Yes | 0, No | 99, Unknown

[crito_critcare]=’1’

This refers to nitric oxide as an inhalant at any time during the patient’s admission. Inhaled nitric oxide is tpically used for hypoxic respiratory failure, among other uses.

Indicate ‘Yes’ if inhaled nitric oxide was used any time during this admission.

SNOMED

1255879001 | Administration of nitric oxide (procedure) |

C1135443, Administration of inhaled nitric oxide

1

1

1

1

1

1

1

outcome

ADVANCED CARE INTERVENTIONS: Record all advanced care interventions given from day of presentation to day of discharge / outcome.

crito_tracheosto

radio

Tracheostomy inserted

1, Yes | 0, No | 99, Unknown

[crito_critcare]=’1’

This refers to the surgical formation of an opening into the trachea through the neck, or the opening so created.

Indicate ‘Yes’ if a tracheostomy was inserted on the patient at any time during admission.

SNOMED

232685002, Insertion of tracheostomy tube (procedure)

C0396630, Insertion of tracheostomy tube

1

1

1

1

1

1

1

outcome

ADVANCED CARE INTERVENTIONS: Record all advanced care interventions given from day of presentation to day of discharge / outcome.

crito_rtt

radio

Renal replacement therapy (RRT) or dialysis

1, Yes | 0, No | 99, Unknown

[crito_critcare]=’1’

This refers to treatments that substitute for the blood-filtering function of the kidneys. It includes dialysis (hemodialysis or peritoneal dialysis), hemofiltration, and hemodiafiltration at any time during the patient’s admission.. It may be intermittent or continuous.

Indicate ‘Yes’, if the patient received continuous renal replacement therapy or intermittent haemodialysis at any time during hospitalisation.

SNOMED

714749008, Continuous renal replacement therapy (procedure) | 895382009, Prolonged intermittent renal replacement therapy (procedure)

C3649547, Continuous Renal Replacement Therapy | C5197699, Prolonged Intermittent Renal Replacement Therapy

treatment

1

1

1

1

1

1

1

1

outcome

ADVANCED CARE INTERVENTIONS: Record all advanced care interventions given from day of presentation to day of discharge / outcome.

crito_rtt_ongoing

radio

Still ongoing?

1, Yes | 0, No | 99, Unknown

[crito_rtt]=’1’

This refers to ongoing renal replacement therapy (RRT) or dialysis

Indicate ‘Yes’, if the patient is still on renal replacement therapy (RRT) or dialysis

1

1

outcome

ADVANCED CARE INTERVENTIONS: Record all advanced care interventions given from day of presentation to day of discharge / outcome.

crito_rtt_dur

number

Number of calendar days on RRT or dialysis duration during admission

number

0

[crito_rtt] = ‘1’

This refers to the total number of days the patient received RRT or dialysis at any time during this admission.

Write the total number of calendar days the patient received RRT or dialysis at any time during this admission. Even if the patient received this more than once in one calendar day (i.e. between 00:00 and 24:00 hours), this counts as one to the total number of days.

treatment

1

1

1

1

1

1

1

outcome

ADVANCED CARE INTERVENTIONS: Record all advanced care interventions given from day of presentation to day of discharge / outcome.

crito_inotropesv

radio

Inotropes / vasopressors

1, Yes | 0, No | 99, Unknown

[crito_critcare]=’1’

This refers to continuous use of a vasopressor or inotrope for at least one hour at any time during the patient’s admission.. Agents include norepinephrine, epinephrine, vasopressin, terlipressin and phenylephrine. Commonly used ‘positive’ inotropes include dobutamine, dopamine, milrinone and adrenaline (epinephrine).

Indicate ‘Yes’, if the patient received Inotropes / vasopressors for at least one hour at any time during hospitalisation.

SNOMED

870386000, Vasopressor therapy (procedure) | 1296972008, Inotropic therapy (procedure)

C5396785, Vasopressor therapy | C5880944, Inotropic therapy

patient_outcome, treatment

1

1

1

1

1

1

1

1

outcome

ADVANCED CARE INTERVENTIONS: Record all advanced care interventions given from day of presentation to day of discharge / outcome.

crito_inotropesv_ongoing

radio

Still ongoing?

1, Yes | 0, No | 99, Unknown

[crito_inotropesv] = ‘1’

This refers to ongoing inotropic/vasoactive therapy.

Indicate ‘Yes’, if the patient is still on inotropic/vasoactive therapy.

1

1

outcome

ADVANCED CARE INTERVENTIONS: Record all advanced care interventions given from day of presentation to day of discharge / outcome.

crito_inotropesv_dur

text

Total inotropes / vasopressor duration during admission (days)

[crito_inotropesv] = ‘1’

The refers to the total number of days during this admission that the patient received inotropic/vasoactive therapy.

Write the total number of calendar days the patient received inotropic or vasoactive therapy at any time during this admission.

treatment

1

1

1

1

1

1

1

outcome

ADVANCED CARE INTERVENTIONS: Record all advanced care interventions given from day of presentation to day of discharge / outcome.

crito_critcareunlst

radio

Other critical care intervention(s) or procedure(s)

1, Yes | 0, No | 99, Unknown

[crito_critcare]=’1’

This refers to any other specific critical care therapeutic intervention(s) or procedure(s) not otherwise characterised that you believe may be relevant.

Indicate ‘Yes’ if other critical care intervention(s) or procedure(s) were used at any time during hospitalisation.

1

1

1

1

1

1

1

1

outcome

ADVANCED CARE INTERVENTIONS: Record all advanced care interventions given from day of presentation to day of discharge / outcome.

crito_critcareunlst_oth

text

If other: Please specify other critical care intervention(s) or procedure(s)

[crito_critcareunlst] = ‘1’

This refers to any other specific critical care therapeutic intervention(s) or procedure(s) not otherwise characterised that you believe may be relevant.

If ‘Yes’, please specify the critical care therapeutic intervention(s) or procedure(s)not otherwise characterised that you believe may be relevant.

1

1

1

1

1

1

1

1

outcome

DIAGNOSIS

diagn_primary

user_list

Primary diagnosis

outcome_Diseases

Refers to the primary (main) diagnosis for which the patient sought care or was admitted to the facility.

Select the most appropriate option which indicates the diagnosis.

1

1

1

1

1

1

1

1

1

outcome

DIAGNOSIS

diagn_primary_type

checkbox

Type of diagnosis

1, Clinical diagnosis | 2, Lab-confirmed | 3, Radiologically confirmed (e.g., chest X-ray, CT) | 99, Unknown |88, Other

Refers to the method used to diagnose the condition. Clinical diagnosis refers to relying on clinical signs and symptoms. Lab confirmed refers to using laboratory investigations. Radiologically confirmed refers to relying on imaging modalities.

Select the most appropriate option which indicates the type of diagnosis.

1

1

1

1

1

1

1

1

1

outcome

DIAGNOSIS

diagn_secondary

user_list

Secondary diagnosis

outcome_Diseases

Refers to the secondary diagnosis which were present at the time the patient sought care or develoeped during the admission.

Select the most appropriate option which indicates the diagnosis.

1

1

1

1

1

1

1

1

outcome

DIAGNOSIS

diagn_secondary_type

checkbox

Type of diagnosis

1, Clinical diagnosis | 2, Lab-confirmed | 3, Radiologically confirmed (e.g., chest X-ray, CT) | 99, Unknown |88, Other

Refers to the method used to diagnose the condition. Clinical diagnosis refers to relying on clinical signs and symptoms. Lab confirmed refers to using laboratory investigations. Radiologically confirmed refers to relying on imaging modalities.

Select the most appropriate option which indicates the type of diagnosis.

1

1

1

1

1

1

1

1

outcome

DIAGNOSIS

diagn_additional

radio

Additional diagnosis

1, Yes | 0, No | 99, Unknown

Refers to the additional diagnosis which were present at the time the patient sought care or develoeped during the admission.

Select the most appropriate option which indicates the diagnosis.

1

1

1

1

1

1

1

1

outcome

DIAGNOSIS

diagn_additional_list

user_list

Additional diagnosis

outcome_Diseases

[diagn_additional]=’1’

Refers to the additional diagnosis which were present at the time the patient sought care or develoeped during the admission.

Select the most appropriate option which indicates the diagnosis.

1

1

1

1

1

1

1

1

outcome

DIAGNOSIS

diagn_additional_type

checkbox

Type of diagnosis

1, Clinical diagnosis | 2, Lab-confirmed | 3, Radiologically confirmed (e.g., chest X-ray, CT) | 99, Unknown |88, Other

[diagn_additional]=’1’

Refers to the method used to diagnose the condition. Clinical diagnosis refers to relying on clinical signs and symptoms. Lab confirmed refers to using laboratory investigations. Radiologically confirmed refers to relying on imaging modalities.

Select the most appropriate option which indicates the type of diagnosis.

1

1

1

1

1

1

1

outcome

DIAGNOSIS

diagn_additional2

radio

Other Additional diagnosis

1, Yes | 0, No | 99, Unknown

Refers to the additional diagnosis which were present at the time the patient sought care or develoeped during the admission.

Select the most appropriate option which indicates the diagnosis.

1

1

1

1

1

1

1

1

outcome

DIAGNOSIS

diagn_additional2_list

user_list

Additional diagnosis

outcome_Diseases

[diagn_additional2]=’1’

Refers to the additional diagnosis which were present at the time the patient sought care or develoeped during the admission.

Select the most appropriate option which indicates the diagnosis.

1

1

1

1

1

1

1

1

outcome

DIAGNOSIS

diagn_additional2_type

checkbox

Type of diagnosis

1, Clinical diagnosis | 2, Lab-confirmed | 3, Radiologically confirmed (e.g., chest X-ray, CT) | 99, Unknown |88, Other

[diagn_additional2]=’1’

Refers to the method used to diagnose the condition. Clinical diagnosis refers to relying on clinical signs and symptoms. Lab confirmed refers to using laboratory investigations. Radiologically confirmed refers to relying on imaging modalities.

Select the most appropriate option which indicates the type of diagnosis.

1

1

1

1

1

1

1

1

outcome

DIAGNOSIS

diagn_mpox_clade

radio

If diagnosis is Mpox: clade

1, Ia | 2, Ib | 3, I sub-type unknown | 4, IIa | 5, IIb | 6, II sub-type unknown | 7, Not done | 99, Unknown| 88, Other

[diagn_primary]=’33’ or [diagn_secondary]=’33’ or [diagn_additional_list]=’33’ or [diagn_additional2_list]=’33’

Refers to the clade of Mpox virus identified during mpox testing.

Select the single most appropriate option that represents the clade of Mpox virus identified during mpox testing.

1

1

outcome

DIAGNOSIS

diagn_mpox_cladeoth

text

Specify other mpox clade

[diagn_mpox_clade]=’88’

Refers to the clade of Mpox virus identified during mpox testing.

If ‘Other’, write the clade of Mpox virus identified during mpox testing.

1

1

outcome

DIAGNOSIS

diagn_denguetyp

radio

If any diagnosis is Dengue: type

1, DENV1 | 2, DENV2 | 3, DENV3 | 4, DENV4

[diagn_primary]=’10’ or [diagn_secondary]=’10’ or [diagn_additional_list]=’10’ or [diagn_additional2_list]=’10’

This refers to the serotype label of the viral species of Dengue virus, which is a single-stranded, positive-sense RNA virus of the Flaviviridae family and Flavivirus genus, detected using the PCR test.

Select the single most appropriate option that represents the serotype label of the viral species of Dengue virus detected using the PCR test.

SNOMED

60588009, Dengue virus, type 1 (organism) | 41328007, Dengue virus, type 2 (organism) | 8467002, Dengue virus, type 3 (organism) | 36700002, Dengue virus, type 4 (organism)

1

outcome

DIAGNOSIS

diagn_dengueclass

radio

What was the final classification of dengue?

1, Uncomplicated dengue | 2, Dengue with warning signs | 3, Severe dengue

[diagn_primary]=’10’ or [diagn_secondary]=’10’ or [diagn_additional_list]=’10’ or [diagn_additional2_list]=’10’

This refers to the 2009, World Health Organisation dengue classification.

Select the most appropriate option corresponding to the final classification of dengue (based on the 2009 World Health Organisation dengue classification).

SNOMED

722862003, Dengue without warning signs (disorder) | 722863008, Dengue with warning signs (disorder) | 20927009, Dengue hemorrhagic fever (disorder)

patient_outcome

1

outcome

DIAGNOSIS

diagn_dengueclass_dss

radio

Dengue shock syndrome

1, Yes | 0, No | 99, Unknown

[diagn_dengueclass]=’3’

Dengue shock syndrome (DSS) refers to severe plasma leakage leading to shock and/or fluid accumulation with respiratory distress.

Indicate ‘Yes’ if the patient experiences this complication of severe dengue which the patient experienced during this admission.

SNOMED

409671005, Dengue shock syndrome (disorder) |

patient_outcome

1

outcome

DIAGNOSIS

diagn_dengueclass_sevbl

radio

Severe bleeding

1, Yes | 0, No | 99, Unknown

[diagn_dengueclass]=’3’

This refers to severe bleeding as evaluated by clinician.

Indicate ‘Yes’ if the patient experiences this complication of severe dengue which the patient experienced during this admission.

patient_outcome

1

outcome

DIAGNOSIS

diagn_dengueclass_sevorgimp

radio

Severe organ impairment

1, Yes | 0, No | 99, Unknown

[diagn_dengueclass]=’3’

This refers to severe organ involvement which can include; Liver involvement is indicated by an AST or ALT greater or equal to 1000 IU/L, nervous system involvement evidenced by impaired consciousness, cardiac involvement (myocarditis), or other organ system involvement.

Indicate ‘Yes’ if the patient experiences this complication of severe dengue which the patient experienced during this admission.

patient_outcome

1

outcome

DIAGNOSIS

diagn_hepatitis_type

radio

If any diagnosis is Hepatitis: Type

1, A | 2, B | 3, C | 4, D | 5, E | 88, Other

[diagn_primary]=’16’ or [diagn_secondary]=’16’ or [diagn_additional_list]=’16’ or [diagn_additional2_list]=’16’

This refers to both DNA and RNA viruses as well viruses from humans and animals, following a non-taxonomic classification of unrelated viruses, that cause liver inflammation and dysfunction.

If ‘Lab confirmed’ Hepatitis virus infection, select the single most appropriate option corresponding to the type of Hepatitis virus detected.

SNOMED

40468003, Viral hepatitis, type A (disorder) | 66071002, Viral hepatitis type B (disorder) | 50711007, Viral hepatitis type C (disorder) | 707341005, Viral hepatitis type D (disorder) | 7111000119109, Viral hepatitis type E (disorder)

1

1

outcome

DIAGNOSIS

diagn_hepatitis_type_oth

text

Specify other hepatitis type

[diagn_hepatitis_type]=’88’

This refers to both DNA and RNA viruses as well viruses from humans and animals, following a non-taxonomic classification of unrelated viruses, that cause liver inflammation and dysfunction.

If ‘Other’, specify the type of Hepatitis virus.

1

1

outcome

DIAGNOSIS

diagn_chick_type

radio

If diagnosis is Chikungunya: Type

1, Chikungunya (classical articular form + fever) | 2, Chikungunya with extra-articular manifestations | 3, Severe chikungunya

[diagn_primary]=’47’ or [diagn_secondary]=’47’ or [diagn_additional_list]=’47’

1

outcome

DIAGNOSIS

diagn_bacte

text

If any diagnosis is Bacterial infection: Specify

[diagn_primary]=’5’ or [diagn_secondary]=’5’ or [diagn_additional_list]=’5’ or [diagn_additional2_list]=’5’

Refers to the method of identifying or excluding a bacterial infection in this admission.

Select the single most appropriate option that represents the method of identifying or excluding a bacterial infection in this admission.

SNOMED

87628006, Bacterial infectious disease (disorder)

1

1

1

1

1

outcome

DIAGNOSIS

diagn_bacte_cont

radio

Bacterial infection (if Lab confirmed)

1, Community acquired | 2, Hospital acquired | 99, Unknown

[diagn_primary]=’5’ or [diagn_secondary]=’5’ or [diagn_additional_list]=’5’ or [diagn_additional2_list]=’5’

Refers to the method of identifying or excluding a bacterial infection in this admission.

Select the single most appropriate option that represents the method of identifying or excluding a bacterial infection in this admission.

SNOMED

87628006, Bacterial infectious disease (disorder)

1

1

1

1

1

outcome

DIAGNOSIS

diagn_pathounlist

list

Other pathogen(s) detected

1, Yes | 0, No | 99, Unknown

pathogens_Other

This refers to the detection of other pathogens, not listed above.

Specify other detected pathogens, not listed above.

1

1

outcome

DIAGNOSIS

diagn_pathounlist_cont

radio

Other pathogen(s) (if Lab confirmed)

1, Community acquired | 2, Hospital acquired | 99, Unknown

[diagn_pathounlist]=’1’

Refers to the method of identifying or excluding a bacterial infection in this admission.

Select the single most appropriate option that represents the method of identifying or excluding a bacterial infection in this admission.

1

1

outcome

JOINT ASSESSMENT

joint_date

date_dmy

Date of assessment (CHICK-DAS Scale)

1

outcome

JOINT ASSESSMENT

joint_tjtdsc

descriptive

Instructions:Tick each joint that is tender on palpation. DAS28 joints are listed below. Ankle joints (non-DAS28) are collected separately for CHIK-DAS TJC30.

1

outcome

JOINT ASSESSMENT

joint_tjt

radio

Tender Joint Count (DAS28 joints) completed

1, Yes | 0, No

1

outcome

JOINT ASSESSMENT

joint_tjt_shoulder

radio

Shoulders (glenohumeral)

0, 0 | 1, 1 | 2, 2 | 99, Unknown

[joint_tjt]=’1’

1

outcome

JOINT ASSESSMENT

joint_tjt_elbow

radio

Elbows

0, 0 | 1, 1 | 2, 2 | 99, Unknown

[joint_tjt]=’1’

1

outcome

JOINT ASSESSMENT

joint_tjt_wrist

radio

Wrists (radiocarpal)

0, 0 | 1, 1 | 2, 2 | 99, Unknown

[joint_tjt]=’1’

1

outcome

JOINT ASSESSMENT

joint_tjt_mcp

radio

Small joints of hand (MCP joints)

0, 0 | 1, 1 | 2, 2 | 3, 3 | 4, 4 | 5, 5 | 6, 6 | 7, 7 | 8, 8 | 9, 9 | 10, 10 | 99, Unknown

[joint_tjt]=’1’

1

outcome

JOINT ASSESSMENT

joint_tjt_pip

radio

Small joints of hand (PIP joints)

0, 0 | 1, 1 | 2, 2 | 3, 3 | 4, 4 | 5, 5 | 6, 6 | 7, 7 | 8, 8 | 9, 9 | 10, 10 | 99, Unknown

[joint_tjt]=’1’

1

outcome

JOINT ASSESSMENT

joint_tjt_knee

radio

Knees

0, 0 | 1, 1 | 2, 2 | 99, Unknown

[joint_tjt]=’1’

1

outcome

JOINT ASSESSMENT

joint_tjt_descankle

descriptive

Tender Ankles (CHIK-DAS addition)

[joint_tjt]=’1’

1

outcome

JOINT ASSESSMENT

joint_tjt_ankle

radio

Ankles (for CHIK-DAS TJC30)

0, 0 | 1, 1 | 2, 2 | 99, Unknown

[joint_tjt]=’1’

1

outcome

JOINT ASSESSMENT

joint_tjt_calc28

calc

TJC28 — Tender Joint Count (DAS28)

if([joint_tjt_shoulder]=99,0,[joint_tjt_shoulder]) + if([joint_tjt_elbow]=99,0,[joint_tjt_elbow]) + if([joint_tjt_wrist]=99,0,[joint_tjt_wrist]) + if([joint_tjt_mcp]=99,0,[joint_tjt_mcp]) + if([joint_tjt_pip]=99,0,[joint_tjt_pip]) + if([joint_tjt_knee]=99,0,[joint_tjt_knee])

1

outcome

JOINT ASSESSMENT

joint_tjt_calc30

calc

TJC30 — Tender Joint Count (CHIK-DAS)

[joint_tjt_calc28] +if([joint_tjt_ankle]=99,0,[joint_tjt_ankle])

1

outcome

JOINT ASSESSMENT

joint_sjtdsc

descriptive

Instructions: Tick each joint that is swollen on examination

1

outcome

JOINT ASSESSMENT

joint_sjt

radio

Swollen Joint Count (DAS28 joints) completed

1, Yes | 0, No

1

outcome

JOINT ASSESSMENT

joint_sjt_shoulder

radio

Shoulders (glenohumeral)

0, 0 | 1, 1 | 2, 2 | 99, Unknown

[joint_sjt]=’1’

1

outcome

JOINT ASSESSMENT

joint_sjt_elbow

radio

Elbows

0, 0 | 1, 1 | 2, 2 | 99, Unknown

[joint_sjt]=’1’

1

outcome

JOINT ASSESSMENT

joint_sjt_wrist

radio

Wrists (radiocarpal)

0, 0 | 1, 1 | 2, 2 | 99, Unknown

[joint_sjt]=’1’

1

outcome

JOINT ASSESSMENT

joint_sjt_mcp

radio

Small joints of hand (MCP joints)

0, 0 | 1, 1 | 2, 2 | 3, 3 | 4, 4 | 5, 5 | 6, 6 | 7, 7 | 8, 8 | 9, 9 | 10, 10 | 99, Unknown

[joint_sjt]=’1’

1

outcome

JOINT ASSESSMENT

joint_sjt_pip

radio

Small joints of hand (PIP joints)

0, 0 | 1, 1 | 2, 2 | 3, 3 | 4, 4 | 5, 5 | 6, 6 | 7, 7 | 8, 8 | 9, 9 | 10, 10 | 99, Unknown

[joint_sjt]=’1’

1

outcome

JOINT ASSESSMENT

joint_sjt_knee

radio

Knees

0, 0 | 1, 1 | 2, 2 | 99, Unknown

[joint_sjt]=’1’

1

outcome

JOINT ASSESSMENT

joint_sjt_calc28

calc

SJC28 — Swollen Joint Count (DAS28)

if([joint_sjt_shoulder]=99,0,[joint_sjt_shoulder]) + if([joint_sjt_elbow]=99,0,[joint_sjt_elbow]) + if([joint_sjt_wrist]=99,0,[joint_sjt_wrist]) + if([joint_sjt_mcp]=99,0,[joint_sjt_mcp]) + if([joint_sjt_pip]=99,0,[joint_sjt_pip]) + if([joint_sjt_knee]=99,0,[joint_sjt_knee])

1

outcome

JOINT ASSESSMENT

joint_crp

number

CRP — C-Reactive Protein (mg/L)

number

1

outcome

JOINT ASSESSMENT

joint_vas

slider

Global Health VAS — Patient-reported

Very well | | Very poor

number

1

outcome

JOINT ASSESSMENT

joint_stiff

radio

Stiffness NRS — Patient-reported (0–10)

0, 0 — No stiffness | 1, 1 | 2, 2 | 3, 3 | 4, 4 | 5, 5 | 6, 6 | 7, 7 | 8, 8 | 9, 9 | 10, 10 — Worst stiffness

1

outcome

JOINT ASSESSMENT

joint_nrs

text

ESR (mm/hr) — if using DAS28-ESR variant

1

outcome

JOINT ASSESSMENT

joint_calc_das28

calc

DAS28 Score

if([joint_tjt]=’1’,0.56*sqrt(if([joint_tjt_calc28]=99,0,[joint_tjt_calc28]))+0.28*sqrt(if([joint_sjt_calc28]=99,0,[joint_sjt_calc28]))+0.36*log(if([joint_crp]=’’,0,[joint_crp])+1)+0.014*[joint_vas]+0.96,’’)

1

outcome

JOINT ASSESSMENT

joint_calc_chikdas

calc

CHIK-DAS Score

if([joint_tjt]=’1’,50+((-1.54+0.080*[joint_stiff]+0.119*if([joint_tjt_ankle]=99,0,[joint_tjt_ankle])+0.310*[joint_calc_das28])/0.0628),’’)

1

outcome

OUTCOME

outco_date

date_dmy

Outcome date

date_dmy

today

This refers to the date of the outcome.

Enter the date of the outcome. (Use the format DD/MM/YYYY)

1

1

1

1

1

1

1

1

1

outcome

OUTCOME

outco_outcome

user_list

Outcome

outcome_Outcome

This refers to the outcome.

Select the outcome that is true on the outcome date. Palliative care includes palliative discharge.

patient_outcome, clinical_features

1

1

1

1

1

1

1

1

1

1

outcome

OUTCOME

outco_selfcare

radio

Ability to self-care at discharge versus before illness

1, Same as before illness | 2, Worse | 3, Better | 99, Unknown

[outco_outcome] = ‘1’

This refers to the ability to perform basic personal care activities and instrumental activities of daily living at discharge compared to before onset of illness.

Select the single most appropriate option that represents the ability to perform basic personal care activities and instrumental activities of daily living at discharge compared to before onset of illness.

1

1

1

1

1

1

outcome

OUTCOME

outco_oxyth

radio

If discharged alive: Oxygen therapy post-discharge treatment

1, Yes | 0, No | 99, Unknown

[outco_outcome] = ‘1’

This refers to the patient’s need for oxygen therapy post-discharge from hospital facility.

Indicate ‘Yes’ if the patient needs oxygen therapy post-discharge from the hospital facility.

1

1

1

1

1

outcome

OUTCOME

outco_carerel

radio

If discharged alive or still hospitalised: Ongoing health care needs relating to this admission for pathogen of interest

1, Yes | 0, No | 99, Unknown

[outco_outcome] = ‘1’ or [outco_outcome]=’2’

This refers to the need for ongoing health care relating to this admission for pathogen of interest

Indicate ‘Yes’ if the patient needs ongoing health care relating to this admission for pathogen of interest.

1

1

1

1

1

1

1

1

1

outcome

OUTCOME

outco_carenonrel

radio

If discharged alive or still hospitalised: Ongoing health care needs NOT related to pathogen episode

1, Yes | 0, No | 99, Unknown

[outco_outcome] = ‘1’ or [outco_outcome]=’2’

This refers to the need for ongoing health care not relating to this admission for pathogen of interest

Indicate ‘Yes’ if the patient needs ongoing health care not relating to this admission for pathogen of interest.

1

1

1

1

1

1

outcome

OUTCOME

outco_carefordif

radio

If Still hospitalised or transfer to other facility: Medically fit for discharge (pathogen resolved) but remains in hospital for other reason (e.g. awaiting alternate care, resident in long term health care or mental health facility)

1, Yes | 0, No | 99, Unknown

[outco_outcome]=’2’ or [outco_outcome]=’3’

This refers to the patient being medical fit for discharge (pathogen infection has resolved) but remaining in hospital for other reasons (e.g. awaiting alternate care, resident in long term health care or mental health facility).

Indicate ‘Yes’ if the patient is medical fit for discharge (pathogen infection has resolved) but remains in hospital for other reasons (e.g. awaiting alternate care, resident in long term health care or mental health facility)

1

1

1

1

1

1

1

1

1

outcome

OUTCOME

outco_transfersite

radio

If transfer to other facility: is the transfer facility a study site?

1, Yes | 0, No | 99, Unknown

[outco_outcome]=’3’

This refers to whether the transfer facility is a study site

Indicate ‘Yes’ if the transfer facility is a study site

1

outcome

OUTCOME

outco_transfersite_pin

text

What is the Participant Identification Number at the new facility?

[outco_transfersite]=’1’

This refers to the participant identification number at the transfer facility.

Indicate the participant identification number at the transfer facility.

1

outcome

OUTCOME

outco_ceiling

radio

Was a maximal level of medical support (‘ceiling of care’) set for the patient during their admission?

1, Yes | 0, No | 99, Unknown

This refers to the maximal level of medical support set for the patient during the current admission.

Indicate ‘Yes’, if a maximal level of medical support for set for this patient during the current admission.

1

1

outcome

OUTCOME

outco_ceiling_descri

notes

Describe what this was (e.g. not for invasive ventilation; not for ICU; or not for CPR)

[outco_ceiling]=’1’

This refers to the maximal level of medical support set for the patient during the current admission.

If ‘Yes’, describe the maximal level of medical support set for this patient during the current admission.

1

1

pregnancy

PREGNANCY DETAILS

preg_form

descriptive

Complete this form only for pregnant patients, postpartum patients (≤28 days after delivery), or neonates whose mothers are not included in the study.

Calendar date (DD–MM–YYYY) on which the CRF was completed.

1

1

pregnancy

PREGNANCY DETAILS

preg_date

date_dmy

Date of form completion

date_dmy

1

1

pregnancy

PREGNANCY DETAILS

pregdet_medirep

radio

Medically assisted reproduction?

1, Yes | 0, No | 99, Unknown

This refers to medical procedures used primarily to address infertility.

1

pregnancy

PREGNANCY DETAILS

pregdet_edd

date_dmy

Estimated date of delivery (EDD)

date_dmy

today

This refers to the expected date on which a pregnant woman will give birth. If not available, provide LMP below if possible

1

1

pregnancy

PREGNANCY DETAILS

pregdet_lmp

date_dmy

Date of last menstrual period (LMP)

date_dmy

today

This refers to the date of the first day of the most recent menstrual cycle.

1

1

pregnancy

PREGNANCY DETAILS

pregdet_parity

number

Parity

number

0

This refers to the number of pregnancies that have progressed to a viable gestational age (usually ≥20 weeks), regardless of whether the infant was born alive or stillborn. Multiple births (e.g., twins) from a single pregnancy are counted as one parity event.

1

1

pregnancy

PREGNANCY DETAILS

pregdet_gravidity

number

Gravidity

number

0

This refer to the total number of times a woman has been pregnant, regardless of the outcome of the pregnancies. This includes current pregnancy, miscarriages, abortions, ectopic pregnancies, and stillbirths.

1

1

pregnancy

PREGNANCY DETAILS

pregdet_prevcs

number

Number of previous surgical (caesarean section) deliveries.

number

0

This refers to the number of previous surgical deliveries of one or more intrauterine fetuses though an abdominal incision (cesaerian section).

1

1

pregnancy

PREGNANCY DETAILS

pregdet_fetnum

number

Number of embryos/foetuses in this pregnancy.

number

0

This refers to the number of embryos/fetuses in this pregnancy

1

1

pregnancy

PREGNANCY-COMORBIDITIES

preg_comor

radio

Co-morbidities during the current pregnancy

1, Yes | 0, No | 99, Unknown

Pre-existing or pregnancy-related medical conditions present at any time during the current pregnancy that may affect maternal or fetal health.

1

1

pregnancy

PREGNANCY-COMORBIDITIES

preg_diabetes

radio

Diabetes

1, Yes | 0, No | 99, Unknown

[preg_comor]=’1’

Disordered glucose metabolism present during the current pregnancy, including pre-existing type 1 or type 2 diabetes mellitus or diabetes first diagnosed during pregnancy (gestational diabetes).

1

1

pregnancy

PREGNANCY-COMORBIDITIES

preg_obesity

radio

Obesity

1, Yes | 0, No | 99, Unknown

[preg_comor]=’1’

A maternal condition defined by a pre-pregnancy or early pregnancy body mass index (BMI) of ≥30 kg/m².

1

1

pregnancy

PREGNANCY-COMORBIDITIES

preg_hypertension

radio

Hypertension

1, Yes | 0, No | 99, Unknown

[preg_comor]=’1’

Elevated blood pressure (≥140/90 mmHg) present during the current pregnancy, whether pre-existing or diagnosed during pregnancy

1

1

pregnancy

PREGNANCY-COMORBIDITIES

preg_sicklecell

radio

Sickle cell

1, Yes | 0, No | 99, Unknown

[preg_comor]=’1’

A hemoglobin disorder characterized by the presence of sickle hemoglobin, including sickle cell disease or sickle cell trait, present during the current pregnancy.

1

1

pregnancy

PREGNANCY-COMORBIDITIES

preg_renal

radio

Renal diseases

1, Yes | 0, No | 99, Unknown

[preg_comor]=’1’

Acute or chronic impairment of kidney function present during the current pregnancy, including chronic kidney disease, nephropathy, or pregnancy-associated renal dysfunction

1

1

pregnancy

PREGNANCY-COMORBIDITIES

preg_immsup

radio

Immunosuppression

1, Yes | 0, No | 99, Unknown

[preg_comor]=’1’

A state of reduced immune function due to medical treatment present during the current pregnancy, such as systemic corticosteroids, biologic therapies, chemotherapy, or post-transplant immunosuppressive drugs.

1

1

pregnancy

PREGNANCY-COMORBIDITIES

preg_immcom

radio

Immunocompromised

1, Yes | 0, No | 99, Unknown

[preg_comor]=’1’

Impaired immune function due to an underlying medical condition present during the current pregnancy, such as HIV infection, congenital immunodeficiency, or malignancy.

1

1

pregnancy

PREGNANCY-COMORBIDITIES

preg_othcomor

radio

Other

1, Yes | 0, No | 99, Unknown

[preg_comor]=’1’

Any other maternal medical condition present during the current pregnancy that is not listed above.

1

1

pregnancy

PREGNANCY-COMORBIDITIES

preg_othcomor_spec

text

If other, specify

[preg_othcomor]=’1’

1

1

pregnancy

PREGNANCY-COMORBIDITIES

preg_smoking

radio

Smoking status

1, Current smoker | 2, Former smoker (stopped PRIOR TO pregnancy) | 3, Former smoker (stopped DURING pregnancy) | 0, Never smoked

Maternal tobacco use

1

1

pregnancy

PREGNANCY-COMORBIDITIES

preg_substance

radio

Substance use during pregnancy

1, Yes | 0, No | 99, Unknown

Use of non-prescribed psychoactive substances (e.g., alcohol, cannabis, opioids, stimulants) at any time during pregnancy.

1

1

pregnancy

PREGNANCY-RELATED COMPLICATIONS

pregcomp_mat

radio

Maternal pregnancy complications?

1, Yes | 0, No | 99, Unknown

1

1

pregnancy

PREGNANCY-RELATED COMPLICATIONS

pregcomp_preecl

radio

Pre-eclampsia

1, Yes | 0, No | 99, Unknown

[pregcomp_mat] = ‘1’

New-onset hypertension (≥140/90 mmHg) after 20 weeks’ gestation with proteinuria or end-organ dysfunction

1

1

pregnancy

PREGNANCY-RELATED COMPLICATIONS

pregcomp_preecl_week

number

Gestational week of onset

number

[pregcomp_preecl]=’1’

Completed gestational week at which the condition was first diagnosed or documented.

1

1

pregnancy

PREGNANCY-RELATED COMPLICATIONS

pregcomp_ecl

radio

Eclampsia

1, Yes | 0, No | 99, Unknown

[pregcomp_mat] = ‘1’

Occurrence of generalized seizures in a woman with pre-eclampsia, not attributable to other causes.

1

1

pregnancy

PREGNANCY-RELATED COMPLICATIONS

pregcomp_ecl_week

number

Gestational week of onset

number

[pregcomp_ecl]=’1’

Completed gestational week at which the condition was first diagnosed or documented.

1

1

pregnancy

PREGNANCY-RELATED COMPLICATIONS

pregcomp_hellp

radio

HELLP Syndrome

1, Yes | 0, No | 99, Unknown

[pregcomp_mat] = ‘1’

Severe pre-eclampsia variant characterized by Hemolysis, Elevated Liver enzymes, and

1

1

pregnancy

PREGNANCY-RELATED COMPLICATIONS

pregcomp_hellp_week

number

Gestational week of onset

number

[pregcomp_hellp]=’1’

Completed gestational week at which the condition was first diagnosed or documented.

1

1

pregnancy

PREGNANCY-RELATED COMPLICATIONS

pregcomp_gdm

radio

Gestational diabetes

1, Yes | 0, No | 99, Unknown

[pregcomp_mat] = ‘1’

Glucose intolerance with onset or first recognition during pregnancy, diagnosed by standard glucose testing.

1

1

pregnancy

PREGNANCY-RELATED COMPLICATIONS

pregcomp_gdm_week

number

Gestational week of onset

number

[pregcomp_gdm]=’1’

Completed gestational week at which the condition was first diagnosed or documented.

1

1

pregnancy

PREGNANCY-RELATED COMPLICATIONS

pregcomp_pih

radio

Pregnancy-induced hypertension

1, Yes | 0, No | 99, Unknown

[pregcomp_mat] = ‘1’

New-onset hypertension after 20 weeks’ gestation without proteinuria or systemic features.

1

1

pregnancy

PREGNANCY-RELATED COMPLICATIONS

pregcomp_pih_week

number

Gestational week of onset

number

[pregcomp_pih]=’1’

Completed gestational week at which the condition was first diagnosed or documented.

1

1

pregnancy

PREGNANCY-RELATED COMPLICATIONS

pregcomp_utbleed

radio

Uterine bleeding

1, Yes | 0, No | 99, Unknown

[pregcomp_mat] = ‘1’

Vaginal bleeding occurring during pregnancy, excluding normal implantation bleeding.

1

1

pregnancy

PREGNANCY-RELATED COMPLICATIONS

pregcomp_utbleed_week

number

Gestational week of onset

number

[pregcomp_utbleed]=’1’

Completed gestational week at which the condition was first diagnosed or documented.

1

1

pregnancy

PREGNANCY-RELATED COMPLICATIONS

pregcomp_malaria

radio

Malaria infection in pregnancy

1, Yes | 0, No | 99, Unknown

[pregcomp_mat] = ‘1’

Laboratory-confirmed Plasmodium infection during pregnancy.

1

1

pregnancy

PREGNANCY-RELATED COMPLICATIONS

pregcomp_malaria_week

number

Gestational week of onset

number

[pregcomp_malaria]=’1’

Completed gestational week at which the condition was first diagnosed or documented.

1

1

pregnancy

PREGNANCY-RELATED COMPLICATIONS

pregcomp_oth

radio

Other maternal pregnancy complication(s)

1, Yes | 0, No | 99, Unknown

[pregcomp_mat] = ‘1’

Completed gestational week at which the condition was first diagnosed or documented.

1

1

pregnancy

PREGNANCY-RELATED COMPLICATIONS

pregcomp_othspec

text

Specify other maternal pregnancy complication(s)

[pregcomp_oth] = ‘1’

1

1

pregnancy

PREGNANCY-RELATED COMPLICATIONS

pregcomp_placfetab

radio

Placental / amniotic fluid / foetal abnormalities identified antenatally

1, Yes | 0, No | 99, Unknown

Structural or functional abnormalities detected by ultrasound or prenatal testing.

1

1

pregnancy

PREGNANCY-RELATED COMPLICATIONS

pregcomp_lowaf

radio

Diminished amniotic fluid

1, Yes | 0, No | 99, Unknown

[pregcomp_placfetab] = ‘1’

Amniotic fluid volume below normal for gestational age.

1

1

pregnancy

PREGNANCY-RELATED COMPLICATIONS

pregcomp_lowaf_week

number

Gestational week of onset

number

[pregcomp_lowaf]=’1’

Completed gestational week at which the condition was first diagnosed or documented.

1

1

pregnancy

PREGNANCY-RELATED COMPLICATIONS

pregcomp_highaf

radio

Excessive amniotic fluid

1, Yes | 0, No | 99, Unknown

[pregcomp_placfetab] = ‘1’

Amniotic fluid volume above normal for gestational age.

1

1

pregnancy

PREGNANCY-RELATED COMPLICATIONS

pregcomp_highaf_week

number

Gestational week of onset

number

[pregcomp_highaf]=’1’

Completed gestational week at which the condition was first diagnosed or documented.

1

1

pregnancy

PREGNANCY-RELATED COMPLICATIONS

pregcomp_pprevia

radio

Placenta previa

1, Yes | 0, No | 99, Unknown

[pregcomp_placfetab] = ‘1’

Placenta partially or completely covering the internal cervical os.

1

1

pregnancy

PREGNANCY-RELATED COMPLICATIONS

pregcomp_pprevia_week

number

Gestational week of onset

number

[pregcomp_pprevia]=’1’

Completed gestational week at which the condition was first diagnosed or documented.

1

1

pregnancy

PREGNANCY-RELATED COMPLICATIONS

pregcomp_plowlying

radio

Low-lying placenta

1, Yes | 0, No | 99, Unknown

[pregcomp_placfetab] = ‘1’

Placenta located near but not covering the internal cervical os.

1

1

pregnancy

PREGNANCY-RELATED COMPLICATIONS

pregcomp_plowlying_week

number

Gestational week of onset

number

[pregcomp_plowlying]=’1’

Completed gestational week at which the condition was first diagnosed or documented.

1

1

pregnancy

PREGNANCY-RELATED COMPLICATIONS

pregcomp_pinsuff

radio

Placental insufficiency

1, Yes | 0, No | 99, Unknown

[pregcomp_placfetab] = ‘1’

Inadequate placental function resulting in impaired fetal growth or wellbeing.

1

1

pregnancy

PREGNANCY-RELATED COMPLICATIONS

pregcomp_pinsuff_week

number

Gestational week of onset

number

[pregcomp_pinsuff]=’1’

Completed gestational week at which the condition was first diagnosed or documented.

1

1

pregnancy

PREGNANCY-RELATED COMPLICATIONS

pregcomp_iugr

radio

Intrauterine growth restriction

1, Yes | 0, No | 99, Unknown

[pregcomp_placfetab] = ‘1’

Estimated fetal weight below the 10th percentile for gestational age due to pathological causes.

1

1

pregnancy

PREGNANCY-RELATED COMPLICATIONS

pregcomp_iugr_week

number

Gestational week of onset

number

[pregcomp_iugr]=’1’

Completed gestational week at which the condition was first diagnosed or documented.

1

1

pregnancy

PREGNANCY-RELATED COMPLICATIONS

pregcomp_othpyn

radio

Other placental / amniotic fluid / foetal abnormalities identified antenatally

1, Yes | 0, No | 99, Unknown

[pregcomp_placfetab] = ‘1’

1

1

pregnancy

PREGNANCY-RELATED COMPLICATIONS

pregcomp_othpspec

text

specify other placental / amniotic fluid / foetal abnormalities identified antenatally

[pregcomp_othpyn] = ‘1’

1

1

pregnancy

PREGNANCY MEDICATIONS

pregmed_immunosup

radio

Any immunosuppressive treatment during pregnancy?

1, Yes | 0, No | 99, Unknown

Use of medications that reduce immune function, including systemic corticosteroids, biologics, chemotherapy, or transplant-related drugs.

1

1

pregnancy

PREGNANCY MEDICATIONS

pregmed_immunosup_num

number

How many immunosuppressive drugs?

number

[pregmed_immunosup] = ‘1’

Number of distinct immunosuppressive agents taken concurrently or sequentially during pregnancy.

1

1

pregnancy

PREGNANCY MEDICATIONS

pregmed_immunosup_name

text

Name(s) of immunosuppressive drug(s).

[pregmed_immunosup] = ‘1’

Generic name(s) of immunosuppressive medication(s) used.

1

1

pregnancy

PREGNANCY MEDICATIONS

pregmed_otheryn

radio

Any other pregnancy medications?

1, Yes | 0, No | 99, Unknown

Use of any prescribed or over-the-counter medication (excluding immunosuppressants) during pregnancy.

1

1

pregnancy

PREGNANCY MEDICATIONS

pregmed_othernum

number

How many pregnancy medications?

number

[pregmed_otheryn] = ‘1’

Number of distinct medications taken during pregnancy.

1

1

pregnancy

PREGNANCY MEDICATIONS

pregmed_othername

text

Name(s) of medication(s).

[pregmed_otheryn] = ‘1’

Generic name(s) of medications used.

1

1

pregnancy

PREGNANCY VACCINES

pregmed_antvacc

checkbox

Antenatal vaccines administered

1, COVID-19 | 2, Hepatitis B | 3, Yellow fever | 4, Chickenpox | 88, Other

Vaccines received during pregnancy (e.g., tetanus, influenza, COVID-19).

1

pregnancy

PREGNANCY VACCINES

pregmed_antvacc_oth

text

If other, specify

[pregmed_antvacc(88)]=’1’

1

pregnancy

PREGNANCY-RELATED TESTING

pregtest_yn

radio

Were biological samples taken tested during pregnancy?

1, Yes | 0, No | 99, Unknown

Any maternal biological specimen collected and analyzed during pregnancy.

1

1

pregnancy

PREGNANCY-RELATED TESTING

pregtest_type

checkbox

Which of the following samples were taken?

1, Amniotic fluid | 2, Placenta | 3, Cord blood | 4, Vaginal swab | 5, Faecal/rectal swab | 6, Pregnancy tissue | 99, Unknown | 88, Other

[pregtest_yn] = ‘1’

Any maternal biological specimen collected and analyzed during pregnancy.

1

1

pregnancy

PREGNANCY-RELATED TESTING

pregtest_desc

text

Describe the sample testing and results.

[pregtest_yn] = ‘1’

Laboratory method used and qualitative/quantitative result.

1

1

pregnancy

PREGNANCY OUTCOME

pregout_bboutc

radio

Pregnancy outcome

1, Livebirth (even if infant died after birth) | 2, Miscarriage (<22 weeks) | 3, Termination by choice | 4, Termination - ultrasound abnormality | 5, Termination - other/unknown reason | 6, Stillbirth (intra-uterine / intrapartum death from 22 gest weeks) | 7, Ectopic pregnancy | 8, Ongoing | 99, Unknown

Final outcome of pregnancy (live birth, stillbirth, miscarriage, termination).

1

1

pregnancy

PREGNANCY OUTCOME

pregout_weeks

number

Gestational age at outcome (completed weeks)

number

[pregout_bboutc] = ‘1’ or [pregout_bboutc] = ‘2’ or [pregout_bboutc] = ‘3’ or [pregout_bboutc] = ‘4’ or [pregout_bboutc] = ‘5’ or [pregout_bboutc] = ‘6’

Gestational age at delivery or pregnancy end, calculated in completed weeks.

1

1

pregnancy

PREGNANCY OUTCOME

pregout_bbtest

radio

Baby tested for mother’s infection of interest?

1, Yes | 0, No | 99, Unknown

Infant tested for the pathogen affecting the mother.

1

1

pregnancy

PREGNANCY OUTCOME

pregout_bbresl

radio

Specify test result from mother’s infection of interest

1, Positive | 0, Negative | 99, Unknown

[pregout_bbtest] = ‘1’

Laboratory result of infant testing related to maternal infection.

1

1

pregnancy

PREGNANCY OUTCOME

pregout_bboutc_termreas

text

If termination for ultrasound abnormality or other reason, specify

[pregout_bboutc] = ‘4’ or [pregout_bboutc] = ‘5’

Specify clinical indication for pregnancy termination.

1

1

pregnancy

PREGNANCY OUTCOME

pregout_bboutc_stillb

radio

If stillbirth: macerated or fresh?

1, Macerated | 2, Fresh | 99, Unknown

[pregout_bboutc] = ‘6’

Fresh: death occurred during labor or shortly before delivery ;Macerated: death occurred days before delivery, with skin change

1

1

pregnancy

PREGNANCY OUTCOME

pregout_matdeath

radio

Did mother die in pregnancy?

1, Yes | 0, No | 99, Unknown

Death occurring during pregnancy or within 42 days of pregnancy end.

1

1

pregnancy

PREGNANCY OUTCOME

pregout_matdeath_age

number

Age at death

number

0

[pregout_matdeath] = ‘1’

Maternal age in completed years at time of death.

1

1

pregnancy

PREGNANCY OUTCOME

pregout_matdeath_cause

text

Cause(s) of death

[pregout_matdeath] = ‘1’

Underlying and contributing medical causes.

1

1

pregnancy

PREGNANCY OUTCOME

pregout_matdeath_place

radio

Place of death

1, At home | 2, Hospital/medical facility | 99, Unknown

[pregout_matdeath] = ‘1’

Location where death occurred (e.g., hospital, home).

1

1

pregnancy

PREGNANCY OUTCOME

pregout_matdeath_time

radio

Death timepoint

1, Pre-delivery | 2, During delivery | 3, Post-delivery (within 40 days) | 99, Unknown

[pregout_matdeath] = ‘1’

Timing relative to pregnancy (antenatal, intrapartum, postpartum).

1

1

pregnancy

PREGNANCY OUTCOME

pregout_othdet

text

Other details about pregnancy, not specified above.

1

1

pregnancy

PREGNANCY OUTCOME

pregout_nbornincl

radio

Is the newborn included in the study?

1, Yes | 0, No | 99, Unknown

Indicates whether the infant is formally enrolled.

1

1

pregnancy

PREGNANCY OUTCOME

pregout_nborpin

text

Indicate the newborn’s Participant Identification Number (PIN)

[pregout_nbornincl]=’1’

Unique study identifier for the newborn.

1

1

neonate

NEWBORN OUTCOMES

nborn_sex

radio

Newborn sex at birth

1, Male | 2, Female | 99, Unknown | 88, Other

This refers to the physical sexual characteristics at birth.

1

1

neonate

NEWBORN OUTCOMES

nborn_modedel

radio

Mode of delivery

1, Vaginal | 2, Assisted vaginal | 3, Elective caesarean (before labour, before rupture of membranes) | 4, Emergency caesarean (after labour and/or rupture of membranes)

This refers to the method by which a foetus is delivered.

1

1

neonate

NEWBORN OUTCOMES

nborn_placedel

radio

Place of delivery

1, At home | 2, Hospital/medical facility | 99, Unknown

This refers to the place of delivery of the foetus.

1

1

neonate

NEWBORN OUTCOMES

nborn_ga

number

Gestational age (weeks)

number

0

This refers to the gestational age of the foetus (written in completed weeks). It can be calculated from the woman’s last menstrual period (LMP) or calculated using the best obstetrical estimated due date (EDD) based on the following formula: Gestational Age = (28 - (EDD - Reference Date)) / 7. The reference date is the date in which you are trying to determine the gestational age.

1

1

neonate

NEWBORN OUTCOMES

nborn_gamethod

radio

How was gestation estimated?

1, LMP | 2, EDD | 99, Unknown

This refers to the method of estimating the gestational age. LMP refers to the date of the first day of the most recent menstrual cycle. EDD refers to the estimated date of delivery.

1

1

neonate

NEWBORN OUTCOMES

nborn_birthweight

number

Newborn weight at birth

number

0

This refers to the measurement of a newborn’s weight immediately after birth, typically recorded within the first minutes of life.

1

1

neonate

NEWBORN OUTCOMES

nborn_birthweight_units

radio

Newborn weight at birth (select units)

1, g | 2, lb

units

Measured weight at birth (g or lb).

1

1

neonate

NEWBORN OUTCOMES

nborn_birthweight_g

number

Newborn weight at birth (g)

number

0

This refers to the measurement of a newborn’s weight immediately after birth, typically recorded within the first minutes of life.

1

1

neonate

NEWBORN OUTCOMES

nborn_birthweight_lb

number

Newborn weight at birth (lb)

number

0

This refers to the measurement of a newborn’s weight immediately after birth, typically recorded within the first minutes of life.

1

1

neonate

NEWBORN OUTCOMES

nborn_length

number

Newborn length at birth

number

0

This refers to the measurement of a newborn’s length from the top of their head to the bottom of one of their heels

1

1

neonate

NEWBORN OUTCOMES

nborn_length_units

radio

Newborn length at birth (select units)

1, cm | 2, in

units

Crown–heel length at birth (inches or cm).

1

1

neonate

NEWBORN OUTCOMES

nborn_length_cm

number

Newborn length at birth (cm)

number

0

This refers to the measurement of a newborn’s length from the top of their head to the bottom of one of their heels

1

1

neonate

NEWBORN OUTCOMES

nborn_length_in

number

Newborn length at birth (in)

number

0

This refers to the measurement of a newborn’s length from the top of their head to the bottom of one of their heels

1

1

neonate

NEWBORN OUTCOMES

nborn_infhc

number

Head circumference at birth

number

0

This refers to the measurement of the largest area of the head (distance from around the back of the head to above the eyebrows and ears).

1

1

neonate

NEWBORN OUTCOMES

nborn_infhc_units

radio

Head circumference at birth (select units)

1, cm | 2, in

units

Occipito-frontal circumference at birth (cm).

1

1

neonate

NEWBORN OUTCOMES

nborn_infhc_cm

number

Head circumference at birth (cm)

number

0

This refers to the measurement of the largest area of the head (distance from around the back of the head to above the eyebrows and ears).

1

1

neonate

NEWBORN OUTCOMES

nborn_infhc_in

number

Head circumference at birth (in)

number

0

This refers to the measurement of the largest area of the head (distance from around the back of the head to above the eyebrows and ears).

1

1

neonate

NEWBORN OUTCOMES

nborn_apgar

number

APGAR score at 5 mins (1-1)

number

1

10

This refers to a score to evaluate a newborn’s adjustment to extrauterine life. Five items - heart rate, respiratory effort, muscle tone, reflex irritability, and color - are evaluated 6 seconds after birth and again five minutes later on a scale from -2, being the lowest, 2 being normal. The five numbers are added for the Apgar score. A score of -3 represents severe distress, 4-7 indicates moderate distress, and a score of 7-1 predicts an absence of difficulty in adjusting to extrauterine life.

1

1

neonate

NEWBORN OUTCOMES

nborn_resusc

radio

Resuscitation required following delivery

1, Yes | 0, No | 99, Unknown

This refers to measures applied for the restoration of life to a newborn.

1

1

neonate

NEWBORN OUTCOMES

nborn_resuscdet

text

Give details

[nborn_resusc] = ‘1’

This refers to measures applied for the restoration of life to a newborn.

1

1

neonate

NEWBORN OUTCOMES

nborn_nicu

radio

Admission to NICU

1, Yes, related to pathogen of interest | 2, Yes, not related to pathogen of interest | 3, No, due to non-availability of NICUs | 0, No | 4, Not applicable | 99, Unknown

This refers to admission of the newborn to the neonatal intensive care unit.

1

1

neonate

NEWBORN OUTCOMES

nborn_hospdur

number

Duration of hospital stay

number

0

This refers to the total duration of hospital stay during the current admisssion (in days).

1

1

neonate

NEWBORN OUTCOMES

nborn_outc

radio

Neonatal outcome

1, Discharged healthy | 2, Discharged with complications/sequelae | 3, Still in neonatal ward | 4, Referred to other hospital | 5, Death | 99, Unknown | 6, Not applicable

This refers to the outcome of the newborn.

neonate

NEWBORN OUTCOMES

nborn_compyn

radio

Did any neonatal complications occur?

1, Yes | 0, No | 99, Unknown

This refers to any complications which occurred during the neonatal period.

1

1

neonate

NEWBORN OUTCOMES

nborn_compsel

checkbox

Select all that apply.

1, Respiratory distress syndrome | 2, Intraventricular haemorrhage | 3, Necrotising enterocolitis | 4, Neonatal encephalopathy | 5, Chronic lung disease | 6, Severe jaundice requiring phototherapy | 7, Major congenital anomaly | 8, Severe infection/sepsis | 9, Meningitis | 10, Exchange transfusion | 99, Unknown | 88, Other

[nborn_compyn] = ‘1’

This refers to any complications which occurred during the neonatal period.

1

1

neonate

NEWBORN OUTCOMES

nborn_compoth

text

If other: Specify

[nborn_compsel(88)] =’1’

This refers to any complications which occurred during the neonatal period.

1

1

neonate

NEWBORN OUTCOMES

nborn_death

radio

Newborn or infant death

1, Yes | 0, No | 99, Unknown

This refers to death of the newborn or infant

1

1

neonate

NEWBORN OUTCOMES

nborn_deathage

number

Age at death

number

0

[nborn_death] = ‘1’

This refers to the age of the newborn or infant at the time of death.

1

1

neonate

NEWBORN OUTCOMES

nborn_deathage_units

radio

Age at death (select units)

1, Days | 2, Months

units

[nborn_death] = ‘1’

1

1

neonate

NEWBORN OUTCOMES

nborn_deathage_days

number

Age at death (Days)

number

0

[nborn_death] = ‘1’

This refers to the age of the newborn or infant at the time of death.

1

1

neonate

NEWBORN OUTCOMES

nborn_deathage_months

number

Age at death (Months)

number

0

[nborn_death] = ‘1’

This refers to the age of the newborn or infant at the time of death.

1

1

neonate

NEWBORN OUTCOMES

nborn_deathcause

text

Cause(s) of death

[nborn_death] = ‘1’

This refers to the cause of death of the newborn or infant.

1

1

neonate

NEWBORN OUTCOMES

nborn_birthdefectyn

radio

Congenital anomaly present?

1, Yes | 0, No | 99, Unknown

This refers to structural or functional abnormalities of the foetus which occurred during development in-utero.

1

1

neonate

NEWBORN OUTCOMES

nborn_birthdefectnum

number

How many?

number

0

[nborn_birthdefectyn] = ‘1’

This refers to structural or functional abnormalities of the foetus which occurred during development in-utero.

1

1

neonate

NEWBORN OUTCOMES

nborn_birthdefect1

text

Describe congenital anomaly

[nborn_birthdefectyn] = ‘1’ and [nborn_birthdefectnum] >= 1

This refers to structural or functional abnormalities of the foetus which occurred during development in-utero.

1

1

neonate

NEWBORN OUTCOMES

nborn_birthdefect1_date

date_dmy

Date of congenital anomaly diagnosis

date_dmy

today

[nborn_birthdefectyn] = ‘1’ and [nborn_birthdefectnum] >= 1

This refers to structural or functional abnormalities of the foetus which occurred during development in-utero.

1

1

neonate

NEWBORN OUTCOMES

nborn_birthdefect2

text

Describe congenital anomaly

[nborn_birthdefectyn] = ‘1’ and [nborn_birthdefectnum] >= 2

This refers to structural or functional abnormalities of the foetus which occurred during development in-utero.

1

1

neonate

NEWBORN OUTCOMES

nborn_birthdefect2_date

date_dmy

Date of congenital anomaly diagnosis

date_dmy

today

[nborn_birthdefectyn] = ‘1’ and [nborn_birthdefectnum] >= 2

This refers to structural or functional abnormalities of the foetus which occurred during development in-utero.

1

1

neonate

NEWBORN OUTCOMES

nborn_birthdefect3

text

Describe congenital anomaly

[nborn_birthdefectyn] = ‘1’ and [nborn_birthdefectnum] >= 3

This refers to structural or functional abnormalities of the foetus which occurred during development in-utero.

1

1

neonate

NEWBORN OUTCOMES

nborn_birthdefect3_date

date_dmy

Date of congenital anomaly diagnosis

date_dmy

today

[nborn_birthdefectyn] = ‘1’ and [nborn_birthdefectnum] >= 3

This refers to structural or functional abnormalities of the foetus which occurred during development in-utero.

1

1

neonate

NEWBORN LESIONS

nborn_lesion

radio

Neonatal skin or mucosal lesions

1, Yes | 0, No | 99, Unknown

This refers to the presence of skin or mucosal lesions observed in the neonate.

1

neonate

NEWBORN LESIONS

nborn_lesion_age

number

Age at onset of lesions (completed weeks)

number

0

[nborn_lesion] = ‘1’

This refers to the age (in completed weeks) at which lesions first appeared.

1

neonate

NEWBORN LESIONS

nborn_lesion_num

radio

Maximum number of lesions observed

1, Mild (< 25 skin lesions) | 2, Moderate (25-99 skin lesions) | 3, Severe (100-250 skin lesions) | 4, Very severe (> 250 skin lesions) | 99, Unknown

[nborn_lesion] = ‘1’

This refers to the maximum number of lesions observed.

1

neonate

NEWBORN LESIONS

nborn_lesion_site

checkbox

Lesion site(s) and pain score (0 = no pain 10 = worst pain)

1, Head/face/neck | 2, Inside of mouth | 3, Torso | 4, Arms and/or hands | 5, Legs and/or feet | 6, External genitalia | 7, Perianal | 8, Vaginal canal | 9, Rectum | 88, Other

[nborn_lesion] = ‘1’

Anatomical location(s) of lesions and pain severity rated 0–10.

1

neonate

NEWBORN LESIONS

nborn_lesion_site_oth

text

If other, specify lesion site

[nborn_lesion_site(88)] = ‘1’

This refers to lesion sites not listed above.

1

neonate

NEWBORN LESIONS

nborn_lesion_type

checkbox

Type(s) of lesions currently present

1, Vesicle | 2, Pustule | 3, Ulcerated lesion | 4, Crusted/scabbed mature lesion | 5, Residual evidence of resolved lesions (scar/discoloration) | 6, Haemorrhagic / bleeding lesions

[nborn_lesion] = ‘1’

This refers to the morphological type(s) of lesions present today.

1

neonate

NEWBORN SIGNS AND SYMPTOMS

nborn_sympt

radio

Neonatal symptoms at clinical examination

1, Yes | 0, No | 99, Unknown

This refers to signs or symptoms identified during neonatal clinical examination.

1

1

neonate

NEWBORN SIGNS AND SYMPTOMS

nborn_fever

radio

Fever

1, Yes | 0, No | 99, Unknown

[nborn_sympt] = ‘1’

In neonates, fever refers to a measured body temperature ?38.0 °C, and hypothermia may also indicate infection.

1

1

neonate

NEWBORN SIGNS AND SYMPTOMS

nborn_cough

radio

Cough

1, Yes | 0, No | 99, Unknown

[nborn_sympt] = ‘1’

This refers to the presence of a cough.

1

1

neonate

NEWBORN SIGNS AND SYMPTOMS

nborn_wheezing

radio

Wheezing

1, Yes | 0, No | 99, Unknown

[nborn_sympt] = ‘1’

Defined as a high-pitched breath sound resulting from a narrowing or obstruction of the small airway.

1

1

neonate

NEWBORN SIGNS AND SYMPTOMS

nborn_rhinorrhoe

radio

Runny nose (rhinorrhoea)

1, Yes | 0, No | 99, Unknown

[nborn_sympt] = ‘1’

Defined as increased mucosal discharge of the nose.

1

1

neonate

NEWBORN SIGNS AND SYMPTOMS

nborn_respdistress

radio

Respiratory distress

1, Yes | 0, No | 99, Unknown

[nborn_sympt] = ‘1’

This refer to a pathological increase in the effort and frequency of breathing movements.

1

1

neonate

NEWBORN SIGNS AND SYMPTOMS

nborn_tachypnoea

radio

Fast breathing (tachypnoea)

1, Yes | 0, No | 99, Unknown

[nborn_sympt] = ‘1’

In neonates, tachypnoea is defined as a respiratory rate greater than 60 breaths per minute.

1

1

neonate

NEWBORN SIGNS AND SYMPTOMS

nborn_nasalflar

radio

Nasal flaring

1, Yes | 0, No | 99, Unknown

[nborn_sympt] = ‘1’

In neonates, nasal flaring refers to widening of the nostrils during inspiration and is a clinical sign of increased work of breathing.

1

1

neonate

NEWBORN SIGNS AND SYMPTOMS

nborn_grunt

radio

Grunting

1, Yes | 0, No | 99, Unknown

[nborn_sympt] = ‘1’

In neonates, grunting refers to an expiratory sound produced by partial closure of the glottis and is a sign of respiratory distress.

1

1

neonate

NEWBORN SIGNS AND SYMPTOMS

nborn_apnoea

radio

Apnoea

1, Yes | 0, No | 99, Unknown

[nborn_sympt] = ‘1’

Defined as a transient absence in spontaneous respiration.

1

1

neonate

NEWBORN SIGNS AND SYMPTOMS

nborn_nasalcongestion

radio

Nasal congestion

1, Yes | 0, No | 99, Unknown

[nborn_sympt] = ‘1’

Defined as reduced ability to pass air through the nasal cavity often leading to mouth breathing.

1

1

neonate

NEWBORN SIGNS AND SYMPTOMS

nborn_vomit

radio

Vomiting

1, Yes | 0, No | 99, Unknown

[nborn_sympt] = ‘1’

Defined as the expulsion of the stomach or small intestines through the mouth.

1

1

neonate

NEWBORN SIGNS AND SYMPTOMS

nborn_diarrhoea

radio

Diarrhoea

1, Yes | 0, No | 99, Unknown

[nborn_sympt] = ‘1’

In neonates, diarrhoea refers to a change in stool frequency or consistency compared with the infant’s normal pattern.

1

1

neonate

NEWBORN SIGNS AND SYMPTOMS

nborn_consti

radio

Constipation

1, Yes | 0, No | 99, Unknown

[nborn_sympt] = ‘1’

In neonates, constipation refers to infrequent, difficult, or painful passage of stools compared with the neonate’s usual bowel pattern.

1

1

neonate

NEWBORN SIGNS AND SYMPTOMS

nborn_lowurine

radio

Reduced urine output

1, Yes | 0, No | 99, Unknown

[nborn_sympt] = ‘1’

In neonates, reduced urine output is defined as urine output <1 ml/kg/hour.

1

1

neonate

NEWBORN SIGNS AND SYMPTOMS

nborn_jaund

radio

Jaundice

1, Yes | 0, No | 99, Unknown

[nborn_sympt] = ‘1’

Defined as a clinical manifestation of hyperbilirubinemia, characterized by the yellowish staining of the skin, mucous membrane and/or sclera.

1

1

neonate

NEWBORN SIGNS AND SYMPTOMS

nborn_skinpallor

radio

Skin pallor

1, Yes | 0, No | 99, Unknown

[nborn_sympt] = ‘1’

This refers to unnatural pale appearance of the skin.

1

1

neonate

NEWBORN SIGNS AND SYMPTOMS

nborn_ftt

radio

Failure to thrive

1, Yes | 0, No | 99, Unknown

[nborn_sympt] = ‘1’

In neonates, failure to thrive refers to inadequate weight gain or weight loss beyond expected physiological limits.”

1

1

neonate

NEWBORN SIGNS AND SYMPTOMS

nborn_hypotonia

radio

Decreased tone / hypotonia

1, Yes | 0, No | 99, Unknown

[nborn_sympt] = ‘1’

This refers to reduced muscle tone compared with what is expected for the neonate’s gestational age and clinical condition.

1

1

neonate

NEWBORN SIGNS AND SYMPTOMS

nborn_bulgefont

radio

Bulging fontanelle

1, Yes | 0, No | 99, Unknown

[nborn_sympt] = ‘1’

In neonates, bulging fontanelle refers to outward bulging or fullness of the anterior fontanelle when the infant is calm and in an upright position, and may indicate increased intracranial pressure.

1

1

neonate

NEWBORN SIGNS AND SYMPTOMS

nborn_hypotherm

radio

Hypothermia

1, Yes | 0, No | 99, Unknown

[nborn_sympt] = ‘1’

This refers to abnormally reduced body temperature due to failed thermoregulation.

1

1

neonate

NEWBORN SIGNS AND SYMPTOMS

nborn_feedingdiff

radio

Feeding difficulty

1, Yes | 0, No | 99, Unknown

[nborn_sympt] = ‘1’

In neonates, feeding difficulty includes poor suck, weak latch, fatigue during feeding, or inability to complete feeds.

1

1

neonate

NEWBORN SIGNS AND SYMPTOMS

nborn_hepatomegally

radio

Hepatomegaly

1, Yes | 0, No | 99, Unknown

[nborn_sympt] = ‘1’

Defined as an pathological enlargement of the liver

1

1

neonate

NEWBORN SIGNS AND SYMPTOMS

nborn_anaemia

radio

Anaemia

1, Yes | 0, No | 99, Unknown

[nborn_sympt] = ‘1’

This refers to a reduction in the number of red blood cells, the amount of haemoglobin, and/or the volume of packed red blood cells relative to neonatal reference ranges.

1

1

neonate

NEWBORN SIGNS AND SYMPTOMS

nborn_seizconv

radio

Seizures

1, Yes | 0, No | 99, Unknown

[nborn_sympt] = ‘1’

Defined as an intermittent abnormality of nervous system physiology characterised by a transient occurrence of sudden, violent, irregular movement of the body, caused by involuntary contraction of muscles due to abnormal excessive or synchronous neuronal activity in the brain.

1

1

neonate

NEWBORN SIGNS AND SYMPTOMS

nborn_keratitis

radio

Keratitis

1, Yes | 0, No | 99, Unknown

[nborn_sympt] = ‘1’

This refers to inflammation of the cornea of the eye.

1

1

neonate

NEWBORN SIGNS AND SYMPTOMS

nborn_conjunctiv

radio

Conjunctivitis

1, Yes | 0, No | 99, Unknown

[nborn_sympt] = ‘1’

Defined as inflammation of the conjunctiva

1

1

neonate

NEWBORN SIGNS AND SYMPTOMS

nborn_ocularother

radio

Other ocular findings

1, Yes | 0, No | 99, Unknown

[nborn_sympt] = ‘1’

Any abnormal eye findings beyond primary diagnosis.

1

1

neonate

NEWBORN SIGNS AND SYMPTOMS

nborn_ocularother_spec

text

Please specify

[nborn_ocularother] = ‘1’

1

1

neonate

NEWBORN SIGNS AND SYMPTOMS

nborn_lymph

radio

Lymphadenopathy

1, Yes-painful | 2, Yes-not painful | 0, No | 99, Unknown

[nborn_sympt] = ‘1’

Defined as a clinical finding of abnormal enlargement of the lymph nodes.

1

1

neonate

NEWBORN SIGNS AND SYMPTOMS

nborn_lymph_site

checkbox

Specify lymphadenopathy site(s)

1, Axillary (arm pits) | 2, Cervical (neck)| 3, Inguinal (groin) | 99, Unknown | 88, Other

[nborn_lymph]=’1’ or [nborn_lymph]=’2’

This refers to the location in which lymphadenopathy was identified.

1

1

neonate

NEWBORN SIGNS AND SYMPTOMS

nborn_lymph_site_oth

text

Specify other lymphadenopathy site(s)

[nborn_lymph_site(88)]=’1’

This refers to the location in which lymphadenopathy was identified.

1

1

neonate

NEWBORN SIGNS AND SYMPTOMS

nborn_haemorrhag

radio

Bleeding (haemorrhage)

1, Yes | 0, No | 99, Unknown

[nborn_haemorrhag] = ‘1’

Defined as the presence of blood in a location in which it is not physiologically normal or loss of blood from the circulation, either internally or externally. This can include epistaxis (blood from nose), gingival bleeding (blood from gums/gingiva), blood from any part of the gastrointestinal tract (gastrointestinal bleeding) or genitourinary tracts (vagina or urethra) including hematuria.

1

1

neonate

NEWBORN SIGNS AND SYMPTOMS

nborn_haemorrhag_site

multi_list

Specify bleeding site(s)

conditions_Site

[nborn_haemorrhag] = ‘1’

This refers to the location of bleeding/haemorrhage site(s).

1

1

neonate

NEWBORN SIGNS AND SYMPTOMS

nborn_haemorrhag_site_oth

text

Specify other bleeding / haemorrhage site(s)

[nborn_haemorrhag_site(88)]=’1’

This refers to the location of bleeding/haemorrhage site(s). Petechiae refer to small reddish or purplish spots in skin or mucous membrane as a result of localised haemorrhage. Nose bleeding refers to haemorrhage localized in the nose. Gum bleeding refers to haemorrhage affecting the gingiva. Gastrointestinal (GI) bleeding refers to haemorrhage in any segment of the gastrointestinal tract from oesophagus to rectum. Urinary tract bleeding refers to haemorrhage originating from any part of the urinary system. Vaginal bleeding refers to haemorrhage originating from vagina, unrelated to normal menstruation.

1

1

neonate

NEWBORN SIGNS AND SYMPTOMS

nborn_other

radio

Other symptom(s)

1, Yes | 0, No | 99, Unknown

[nborn_sympt] = ‘1’

This refers to the presence of an alternative sign or abnormality not listed above.

1

1

neonate

NEWBORN SIGNS AND SYMPTOMS

nborn_other_spec

text

If yes, specify other

[nborn_other]=’1’

1

1

neonate

NEWBORN SIGNS AND SYMPTOMS

nborn_imaging

radio

Imaging conducted

1, Cranial ultrasound | 2, MRI | 88, Other | 0, None

[nborn_sympt] = ‘1’

Any radiologic study performed (e.g., ultrasound, MRI, X-ray).

1

1

neonate

NEWBORN SIGNS AND SYMPTOMS

nborn_imaging_oth

text

Specify

[nborn_imaging] = ‘88’

1

1

neonate

NEWBORN SIGNS AND SYMPTOMS

nborn_imaging_res

radio

Imaging results

1, Normal findings | 2, Abnormal findings

[nborn_imaging] <> ‘0’

Summary of findings.

1

1

neonate

NEWBORN SIGNS AND SYMPTOMS

nborn_imaging_res_det

text

If abnormal findings, provide details

[nborn_imaging_res] = ‘2’

Description of abnormal imaging findings.

1

1

neonate

NEWBORN SIGNS AND SYMPTOMS

nborn_conginfectyn

radio

Congenitally-acquired infections

1, Yes | 0, No | 99, Unknown

This refers to suspected or confirmed infections in the newborn that are acquired in utero and persisting after birth.

1

1

neonate

NEWBORN SIGNS AND SYMPTOMS

nborn_conginfecttype

checkbox

Type of congenitally-acquired infections

1, CMV | 2, Syphilis | 3, Toxoplasmosis | 4, HIV | 5, HCV | 6, HBV | 7, HSV-1 | 8, HSV-2 | 99, Unknown | 88, Other

[nborn_conginfectyn] = ‘1’

This refers to type(s) of suspected or confirmed infections in the newborn that are acquired in utero and persisting after birth.

1

1

neonate

NEWBORN SIGNS AND SYMPTOMS

nborn_conginfectother

text

Specify other congenitally-acquired infections

[nborn_conginfecttype(88)] = ‘1’

This refers to other suspected or confirmed infections, not specified above, in the newborn that are acquired in utero and persisting after birth.

1

1

neonate

NEWBORN SIGNS AND SYMPTOMS

nborn_breastfed

radio

Was baby ever breastfed?

1, Yes | 0, No | 99, Unknown

Infant received breast milk at least once after birth.

1

1

neonate

NEWBORN SIGNS AND SYMPTOMS

nborn_breastfed_status

radio

Breastfeeding status

1, Currently breastfed | 0, Breastfeeding discontinued

[nborn_breastfed]=’1’

Current breastfeeding status of the infant at the time of assessment, regardless of exclusivity.

1

1

neonate

NEWBORN SIGNS AND SYMPTOMS

nborn_breastfed_dur

number

If breastfeeding discontinued, how long did breastfeeding last? (in weeks)

number

[nborn_breastfed_status]=’0’

Total number of weeks breastfeeding occurred before permanent discontinuation.

1

1

neonate

NEWBORN LABORATORY TESTS

nborn_labtestyn

radio

Infant Mpox testing performed?

1, Yes | 0, No | 99, Unknown

Laboratory testing conducted to detect Mpox virus in the infant.

1

neonate

NEWBORN LABORATORY TESTS

nborn_specimen

radio

Mpox specimen type

1, Amniotic fluid | 2, Cord blood during pregnancy | 3, Cord blood after delivery | 4, Placental sample during pregnancy | 5, Placental sample after delivery | 6, Skin lesion | 7, Blood | 8, Nasopharyngeal swab | 9, Urine |88, Other

[nborn_labtestyn] = ‘1’

Biological sample used (e.g., lesion swab, blood).

1

neonate

NEWBORN LABORATORY TESTS

nborn_specimenother

text

Specify

[nborn_specimen] = ‘88’

1

neonate

NEWBORN LABORATORY TESTS

nborn_labmethod

radio

Mpox laboratory method

1, PCR | 2, Ortho PCR | 3, Serology | 999, Other

[nborn_labtestyn] = ‘1’

Diagnostic technique used (e.g., PCR).

1

neonate

NEWBORN LABORATORY TESTS

nborn_pcrres

radio

PCR result

1, Positive | 0, Negative

[nborn_labmethod] = ‘1’

Qualitative PCR outcome (positive/negative).

1

neonate

NEWBORN LABORATORY TESTS

nborn_pcrct

number

PCR Cycle Threshold (CT)

number

0

[nborn_labmethod] = ‘1’

Number of amplification cycles required to detect viral DNA; lower CT indicates higher viral load.

1

neonate

NEONATE DETAILS

nborn_motherincl

radio

Is the mother included in the study ?

1, Yes | 0, No | 99, Unknown

This refers to inclusion of the mother in the same study.

1

1

neonate

NEONATE DETAILS

nborn_motherpin

text

specify their PIN

[nborn_motherincl]=’1’

This refers to the participant identification number allocated to the mother of a newborn in the study.

1

1

follow_up

FOLLOW-UP ASSESSMENT

follow_date

date_dmy

Date of follow up

date_dmy

today

This refers to the date of the patient follow-up.

Enter the date of follow up. (Use the format DD/MM/YYYY)

1

1

1

1

1

follow_up

FOLLOW-UP ASSESSMENT

follow_outcome

user_list

Patient outcome

followup_outcome

This refers to an assessment of the patient outcome on follow-up.

Select the single most appropriate option that represents the patient outcome.

1

1

1

1

1

follow_up

FOLLOW-UP ASSESSMENT

follow_outcome_date

date_dmy

First / earliest date on which the selected outcome was true

date_dmy

today

This refers to the first / earliest date on which the selected outcome was true.

Enter the first or earliest date in which the selected outcome occurred. (Use the format DD/MM/YYYY)

1

1

1

1

follow_up

FOLLOW-UP ASSESSMENT

follow_outcome_reas

text

Reason for outcome

[follow_outcome]=’11’

This refers to re-hospitalisation due to infection with pathogen of interest.

Write the date of hospitalisation. Use DD/MM/YYYY format.

SNOMED

1269557005, Reason for hospital admission (observable entity)

C5817481, Reason for hospital admission

1

1

1

1

follow_up

FOLLOW-UP ASSESSMENT

follow_skindamage

radio

Is the patient’s skin damaged following resolution of acute illness

1, Yes | 0, No | 99, Unknown

[follow_outcome]<>’3’ and [follow_outcome]<>’7’ and [follow_outcome]<>’6’ and [follow_outcome]<>’8’

This refers to the presence of scarring, altered pigmentation, contractures or other deformities secondary to resolved skin lesions.

Indicate ‘Yes’ if the patient has any skin damage related to the resolution of active skin lesions.

1

1

follow_up

FOLLOW-UP ASSESSMENT

follow_skindamage_type

checkbox

Select all that apply

1, Atrophic scars | 2, Hypertrophic scars | 3, Deformities | 4, Hypopigmentation | 5, Hyperpigmentation | 6, Contractures | 88, Other

[follow_skindamage]=’1’

This refers to the presence of scarring, altered pigmentation, contractures or other deformities secondary to resolved skin lesions. Atrophic scars refer to scars that form a depression compared to the level of the surrounding skin because of damage to the collagen, fat or other tissues below the skin. Hypertrophic scar refers to a permanent mark on the skin caused by deposits of excessive amounts of collagen during wound healing. It is elevated and does not extend beyond the original boundaries of the wound; the elevation may stabilize or regress spontaneously. Deformities refer to alterations or deviations from normal shape or size which result in a disfigurement to normal body structures. Hypopigmentation refers to abnormal lightening of skin due to decreased melanin production or deposition. Hyperpigmentation refers to darkening of the skin due to excessive melanin deposition. Contracture refers to a prolonged shortening of the muscle or other soft tissue around a joint, preventing movement of the joint.

Select all type(s) of skin damage following resolution of acute illness.

1

1

follow_up

FOLLOW-UP ASSESSMENT

follow_skindamage_type_oth

notes

Specify other type of skin damage

[follow_skindamage_type(88)]=’1’

This refers to the presence of any other type(s) of skin damage that you feel is secondary to infection with pathogen of interest, and is pertinent to include here.

Write the other type(s) of skin damage following resolution of acute illness.

1

1

follow_up

FOLLOW-UP ASSESSMENT

follow_seque

radio

Does the patient have any sequelae?

1, Yes | 0, No | 99, Unknown

[follow_outcome]<>’3’ and [follow_outcome]<>’7’ and [follow_outcome]<>’6’

This refers to any other complication(s) or sequalae, not specified above.

Indicate ‘Yes’ if the patient has any other complication(s) or sequalae not specified above.

1

1

1

1

1

follow_up

FOLLOW-UP ASSESSMENT

follow_seque_type

multi_list

Select all that apply

followup_sequelae

[follow_seque]=’1’

This refers to any other complication(s) or sequalae, not specified above. Decreased vision refers to vision considered to be inferior to normal vision as represented by accepted standards of acuity, field of vision, or motility. Blindness refers to the inability to see or the loss or absence of perception of visual stimuli. Urethral stricture refers to the narrowing of the urethra associated with inflammation or scar tissue. Vaginal stricture refers to narrowing of the vagina owing to scar formation. Rectal stricture refers to narrowing of the rectum secondary to scar formation. Dyspareunia refers to recurrent genital pain occurring during, before, or after sexual intercourse in either the males or the females. Depression refers to an affective disorder manifested by either a dysphoric mood or loss of interest or pleasure in usual activities and the mood disturbance is prominent and relatively persistent.

Select all other complication(s) or sequalae, not specified above.

1

1

1

1

follow_up

BARTHEL INDEX SCORE

follow_barthel

radio

Is the Barthel Index being assessed for this patient to capture daily living ability data?

1, Yes | 0, No | 99, Unknown

Following questions are used to calculate the Barthel Index score: The Barthel Index for Activities of Daily Living is an ordinal scale which measures a person’s ability to complete activities of daily living/

Indicate ‘Yes’ if this score is being assessed on the follow-up visit to capture quality of life.

1

follow_up

BARTHEL INDEX SCORE

follow_barthel_feeding

radio

Are you able to feed yourself?

1, Independent | 2, Needs some help | 3, Needs extensive help | 4, Unable to feed oneself

[follow_barthel]=’1’

This refers to the ability of the patient to feed themselves.

Select the most appropriate option which most closely corresponds with the patient’scurent level of ability. Record actual, and not potential, functioning.

1

follow_up

BARTHEL INDEX SCORE

follow_barthel_bathing

radio

Are you able to bathe yourself?

1, Independent | 2, Needs some help | 3, Needs extensive help | 4, Unable to bathe oneself

[follow_barthel]=’1’

This refers to the ability of the patient to bathe themselves.

Select the most appropriate option which most closely corresponds with the patient’scurent level of ability. Record actual, and not potential, functioning.

1

follow_up

BARTHEL INDEX SCORE

follow_barthel_grooming

radio

Are you able to groom yourself?

1, Independent | 2, Needs some help | 3, Needs extensive help | 4, Unable to groom oneself

[follow_barthel]=’1’

This refers to the ability of the patient to groom themselves.

Select the most appropriate option which most closely corresponds with the patient’scurent level of ability. Record actual, and not potential, functioning.

1

follow_up

BARTHEL INDEX SCORE

follow_barthel_dressing

radio

Are you able to dress yourself?

1, Independent | 2, Needs some help | 3, Needs extensive help | 4, Unable to dress oneself

[follow_barthel]=’1’

This refers to the ability of the patient to dress themselves.

Select the most appropriate option which most closely corresponds with the patient’scurent level of ability. Record actual, and not potential, functioning.

1

follow_up

BARTHEL INDEX SCORE

follow_barthel_bowel

radio

Do you have control over your bowels?

1, Continent | 2, Occasional incontinence | 3, Frequent incontinence | 4, Incontinent

[follow_barthel]=’1’

This refers to voluntary control of bowel movement. Continent refers to complete voluntary control. Occasional incontinence refers to loss of voluntary control once a week. Frequent incontinence refers to loss of voluntary control more than once a week. Incontinent refers to complete lack of voluntary control, inability to manage alone or requiring use of enemas for bowel movement.

Select the most appropriate option which most closely corresponds with the patient’scurent level of ability. Record actual, and not potential, functioning.

1

follow_up

BARTHEL INDEX SCORE

follow_barthel_bladder

radio

Do you have control over your bladder?

1, Continent | 2, Occasional incontinence | 3, Frequent incontinence | 4, Incontinent

[follow_barthel]=’1’

This refers to voluntary control of bowel movement. Continent refers to complete voluntary control. Occasional incontinence refers to loss of voluntary control once a week. Frequent incontinence refers to loss of voluntary control more than once a week. Incontinent refers to complete lack of voluntary control, inability to manage alone or requiring catherisation.

Select the most appropriate option which most closely corresponds with the patient’scurent level of ability. Record actual, and not potential, functioning.

1

follow_up

BARTHEL INDEX SCORE

follow_barthel_toilet

radio

Are you able to use the toilet by yourself?

1, Independent | 2, Needs some help | 3, Needs extensive help | 4, Unable to use the toilet

[follow_barthel]=’1’

This refers to ability to use toilet independently.

Select the most appropriate option which most closely corresponds with the patient’scurent level of ability. Record actual, and not potential, functioning.

1

follow_up

BARTHEL INDEX SCORE

follow_barthel_transfer

radio

Are you able to transfer from bed to chair and back?

1, Independent | 2, Needs some help | 3, Needs extensive help | 4, Unable to transfer

[follow_barthel]=’1’

This refers to ability to transfer from bed to chair and back.

Select the most appropriate option which most closely corresponds with the patient’scurent level of ability. Record actual, and not potential, functioning.

1

follow_up

BARTHEL INDEX SCORE

follow_barthel_walking

radio

Are you able to walk on a flat surface?

1, Independent | 2, Needs some help | 3, Uses a wheelchair independently | 4, Unable to walk

[follow_barthel]=’1’

This refers to ability to walk on flat suraces.

Select the most appropriate option which most closely corresponds with the patient’scurent level of ability. Record actual, and not potential, functioning.

1

follow_up

BARTHEL INDEX SCORE

follow_barthel_stairs

radio

Are you able to go up and down stairs?

1, Independent | 2, Needs some help | 3, Unable to use stairs

[follow_barthel]=’1’

This refers to ability to mobilise up and down a flight of stairs.

Select the most appropriate option which most closely corresponds with the patient’scurent level of ability. Record actual, and not potential, functioning.

1

withdrawal

WITHDRAWAL

withd_date

date_dmy

Date of withdrawal

date_dmy

today

This refers to withdrawal of the patient consent.

Enter the date of withdrawal of patient consent. (Use the format DD/MM/YYYY)

1

withdrawal

WITHDRAWAL

withd_reas

text

Reason for withdrawal

This refers to withdrawal of the patient consent.

Write the reason for withdrawal of patient consent.

1

withdrawal

WITHDRAWAL

withd_active

radio

Did the participant withdraw from active participation in the study?

1, Yes | 0, No | 99, Unknown

This refers to withdrawal of the patient consent.

Indicate ‘Yes’ if the participant withdrew from active participation in the study.

1

withdrawal

WITHDRAWAL

withd_datacoll

radio

Did the participant withdraw consent to use data collected up until the point of withdrawal?

1, Yes | 0, No | 99, Unknown

This refers to withdrawal of the patient consent.

Indicate ‘Yes’ if the participant withdrew consent to use data collected up until the point of withdrawal.

1

withdrawal

WITHDRAWAL

withd_datasample

radio

Did the participant withdraw consent to use samples collected up until the point of withdrawal?

1, Yes | 0, No | 99, Unknown

This refers to withdrawal of the patient consent.

Indicate ‘Yes’ if the participant withdrew consent to use samples collected up until the point of withdrawal.

1