Daily Form - isaric4c/wiki GitHub Wiki

Variable / Field Name Section Header Field Type Field Label Choices or Calculations
daily_form_v9_6_onwards text Note that from V9.6 of the CRF, if completing TIER 0 details,
then you DO NOT NEED TO COMPLETE THIS FORM FOR DAYS 3, 6 and 9
daily_form_desc_text1 text 1. DAILY ASSESSMENT FORM (complete one form on admission,
one form on admission to ICU, and daily up to 14 days or until discharge or death
if earlier)
daily_form_desc_text2 text DAILY FORM complete per Tier of activity AND if research samples are collected Page 1 of 1 (may not be the date of completion)
daily_dsstdat text (date_dmy) DATE OF ASSESSMENT
daily_hoterm Record the worst value from 00:00-24:00 taken on day of assessment (if Not Available write 'N/A')): radio Current admission to ICU/ITU/IMC/HDU 1, Yes ; 2, No ; 3, N/A
daily_temp_vsorres text Highest Temperature
daily_temp_vsorresu radio Highest Temperature Unit 1, °C ; 2, °F
daily_temp_vsorresnk radio Highest Temperature N/K 1, N/K
daily_fi02_lbyn radio FiO2 available / Any supplemental oxygen? 1, Yes ; 2, No ; 3, N/K
daily_fio2_lborres text FiO2 (0.21-1.0)
daily_fio2b_lborres text FiO2 %
daily_fio2c_lborres text FiO2 L/min (highest
daily_sa02_lbyn radio SaO2 (Oxygen saturation in newer CRF) available? (% (lowest for newer CRF)) 1, Yes ; 2, No ; 3, N/K
daily_sao2_lborres text SaO2 (SpO2 on the newer CRF) (at time of FiO2 above)
daily_pao2_lbyn yesno PaO2 available? (at time of FiO2 above) 1, Yes ; 0, No
daily_pao2_lborres text PaO2:
daily_pao2_lborresu dropdown PaO2 unit: 1, kPa ; 2, mmHg
daily_pao2_lbspec dropdown PaO2 sample type (from same blood gas record as PaO2) 1, Arterial ; 2, Venous ; 3, Capillary ; 4, N/A
daily_pco2_lbyn radio PCO2 available? (from same blood gas record as PaO2) 1, Yes ; 2, No
daily_pco2_lborres text PCO2
daily_pco2_lborresu dropdown PCO2 Unit 1, kPa ; 2, mmHg
daily_ph_lbyn yesno pH available 1, Yes ; 0, No
daily_ph_lborres text pH
daily_hco3_lbyn yesno HCO3- available 1, Yes ; 0, No
daily_hco3_lborres text HCO3-
daily_hco3_lborresu dropdown HCO3- Unit 1, mEq/L ; 2,  mmol/L
daily_baseex_lbyn yesno Base excess available 1, Yes ; 0, No
daily_baseex_lborres text Base excess (mmol/L)
daily_rr text RR breaths per minute (highest)
daily_rr_nk radio RR breaths per minute N/K 1, N/K
avpu_vsorres radio AVPU 1, Alert ; 2, Verbal ; 3, Pain ; 4, Unresponsive ; 5, N/K
daily_gcs_lbyn radio Glasgow Coma Score available? 1, Yes ; 2, No ; 3, N/K
daily_gcs_vsorres text Glasgow Coma Score: (out of 15)
systolic_vsyn yesno Systolic Blood Pressure available? 1, Yes ; 0, No
systolic_vsorres text Systolic Pressure (mmHg)
diastolic_vsyn yesno Diastolic Blood Pressure available? 1, Yes ; 0, No
diastolic_vsorres text Diastolic Pressure (mmHg)
daily_meanart_lbyn radio Mean Arterial Pressure available? 1, Yes ; 0, No
daily_meanart_vsorres text Mean Arterial Pressure (mmHg)
daily_urine_lbyn radio Urine flow rate available? 1, Yes ; 2, Estimated ; 0, No
daily_urine_lborres text Urine flow rate (mL/24 hours)
daily_noninvasive_prtrt radio Non-invasive ventilation (e.g. NIV (if shorter CRF), BIPAP, CPAP)? 1, Yes ; 2, No ; 3, N/A
daily_invasive_prtrt radio Invasive ventilation? 1, Yes ; 2, No ; 3, N/A
daily_nasaloxy_cmtrt radio High-flow nasal canula? 1, Yes ; 2, No ; 3, N/A
daily_ecmo_prtrt radio ECLS/ECMO 1, Yes ; 2, No ; 3, N/A
daily_rrt_cmtrt radio Dialysis / Hemofiltration 1, Yes ; 2, No ; 3, N/A
daily_inotrope_cmyn radio Any vasopressor / inotropic support? 1, Yes ; 2, No ; 3, N/A
daily_dopless5_cmtrt radio Dopamine < 5 µg/min OR Dobutamine OR Milrinone OR Levosimendan: 1, Yes ; 2, No ; 3, N/A
daily_dop5to15_cmtrt radio Dopamine 5-15 µg/min OR Epinephrine/Norepinephrine < 0.1 µg/kg/min
OR Vasopressin OR Phenylephrine:		 1, Yes ; 2, No ; 3, N/A
daily_dopgr15_cmtrt radio Dopamine > 15 µg/min OR Epinephrine/Norepinephrine > 0.1 µg/kg/min: 1, Yes ; 2, No ; 3, N/A
daily_neuro_cmtrt radio Neuromuscular blocking agents? 1, Yes ; 2, No ; 3, N/A
daily_nitritc_cmtrt radio Inhaled Nitric Oxide ? 1, Yes ; 2, No ; 3, N/A
daily_prone_cmtrt radio Prone Positioning 1, Yes ; 2, No ; 3, N/A
daily_trach_prperf radio Tracheostomy inserted? 1, Yes ; 2, No ; 3, N/A
daily_prperf radio Other intervention or procedure? 1, Yes ; 2, No ; 3, N/A
daily_other_prtrt text If YES other intervention, Specify,
remdesivir radio Is patient receiving Remdesivir through EAMS (Early Access to Medicine Scheme) criteria? 1, Yes ; 0, No ; 2, N/K
remdesivir_day text Which day of Remdesivir therapy is this: (number)
remdesivir_last_dose radio Is this the intended last dose? 1, Yes ; 0, No ; 2, N/K
remdesivir_text text A DAILY CRF must be completed for each day of remdesivir administration and for Day 14
after first dose of remdesivir (if patient remains admitted). If not already done,
please retrospectively complete the ADMISSION CRF and any scheduled DAILY CRF forms.
daily_lab_text text DAILY LABORATORY RESULTS
daily_lbperf yesno Results available for sample taken on the date in section 1 above ? 1, Yes ; 0, No
daily_lbdat text (date_dmy) Date of assessment
daily_hb_lbyn radio Haemoglobin available 1, Yes ; 0, No ; 3, N/K
daily_hbop_lborres dropdown Haemoglobin < or > (optional) 1, < ; 2, >
daily_hb_lborres text Haemoglobin
daily_hb_lborresu dropdown Haemoglobin Unit 1, g/L ; 2, g/dL
daily_wbc_lbyn radio WBC count available 1, Yes ; 0, No ; 3, N/K
daily_wbcop_lborres dropdown WBC count < or > (optional)
daily_wbc_lborres text WBC count
daily_wbc_lborresu dropdown WBC Unit 1, x 10^9 / L ; 2, x 10³/μL
daily_lymp_lbyn radio Lymphocyte count available 1, Yes ; 0, No ; 3, N/K
daily_lympop_lbyn dropdown Lymphocyte count < or > (optional) 1, < ; 2, >
daily_lymp_lborres text Lymphocyte count
daily_lymp_lborresu dropdown Lymphocyte count Unit 1, cells/μL ; 2, x 10^9 / L ; 3, x 10³/μL
daily_neutro_lbyn radio Neutrophil count available 1, Yes ; 0, No ; 3, N/K
daily_neutroop_lbyn dropdown Neutrophil count < or > (optional) 1, < ; 2, >
daily_neutro_lborres text Neutrophil count
daily_neutro_lborresu dropdown Neutrophil count Unit 1, cells/μL ; 2, x 10^9 / L ; 3, x 10³/μL
daily_haematocrit_lbyn yesno Haematocrit available
daily_haematocrit_lborres text Haematocrit
daily_haematocrit_lborresu dropdown Haematocrit Unit 1, % ; 2, L/L
daily_plt_lbyn radio Platelets available 1, Yes ; 0, No ; 3, N/K
daily_pltop_lborres dropdown Platelet count < or > (optional) 1, < ; 2, >
daily_plt_lborres text Platelet Count
daily_plt_lborresu dropdown Platelets Unit 1, x 10^9 / L ; 2, x 10³/μL
daily_aptt_lbyn radio APTT/APTR available 1, Yes ; 0, No ; 3, N/K
daily_apttop_lborres dropdown APTT/APTR < or > (optional) 1, < ; 2, >
daily_aptt_lborres text APTT/APTR (seconds)
daily_pt_inr_lbyn dropdown PT or INR available 1, PT done ; 2, INR done ; 3, PT or INR not done ; 4, N/K
daily_ptop_lborres dropdown PT < or > (optional) 1, < ; 2, >
daily_pt_lborres text PT (seconds)
daily_inrop_lborres dropdown INR < or > (optional) 1, < ; 2, >
daily_inr_lborres text INR
daily_esr_lbyn radio ESR available 1, Yes ; 0, No ; 3, N/K
daily_esrop_lbyn dropdown ESR < or > (optional) 1, < ; 2, >
daily_esr_lborres text ESR (mm/hr)
daily_ferr_lbyn radio Ferritin available 1, Yes ; 0, No ; 3, N/K
daily_ferrop_lbyn dropdown Ferritin < or > (optional) 1, < ; 2, >
daily_ferr_lborres text Ferritin
daily_ferr_lborresu dropdown Ferritin Unit 1, μL/L ; 2, ng/mL
daily_alt_lbyn radio ALT / SGPT available 1, Yes ; 0, No ; 3, N/K
daily_altop_lbyn dropdown ALT / SGPT < or > (optional) 1, < ; 2, >
daily_alt_lborres text ALT / SGPT (U/L)
daily_bil_lbyn radio Total Bilirubin available 1, Yes ; 0, No ; 3, N/K
daily_bilop_lborres dropdown Total Bilirubin < or > (optional) 1, < ; 2, >
daily_bil_lborres text Total Bilirubin
daily_bil_lborresu dropdown Total Bilirubin Unit 1, μmol/L ; 2, mg/dL
daily_ast_lbyn radio AST/SGOT available 1, Yes ; 0, No ; 3, N/K
daily_astop_lborres dropdown AST/SGOT < or > (optional) 1, < ; 2, >
daily_ast_lborres text AST/SGOT (U/L)
daily_glucose_lbyn radio Glucose available 1, Yes ; 0, No ; 3, N/K
daily_glucoseop_lborres dropdown Glucose < or > (optional) 1, < ; 2, >
daily_glucose_lborres text Glucose
daily_glucose_lborresu dropdown Glucose Unit 1, mmol/L ; 2, mg/dL
daily_bun_lbyn radio Blood Urea Nitrogen (urea) available 1, Yes ; 0, No ; 3, N/K
daily_bunop_lborres dropdown Blood Urea Nitrogen (urea) < or > (optional) 1, < ; 2, >
daily_bun_lborres text Blood Urea Nitrogen (urea)
daily_bun_lborresu dropdown Blood Urea Nitrogen (urea) Unit 1, mmol/L ; 2, mg/dL
daily_lactate_lbyn radio Lactate available 1, Yes ; 0, No ; 3, N/K
daily_lactateop_lbyn dropdown Lactate < or > (optional) 1, < ; 2, >
daily_lactate_lborres text Lactate
daily_lactate_lborresu dropdown Lactate Unit 1, mmol/L ; 2, mg/dL
daily_ldh_lbyn radio Lactate dehydrogenase (LDH) available? 1, Yes ; 0, No ; 3, N/K
daily_ldhop_lborres dropdown LDH < or > (optional) 1, < ; 2, >
daily_ldh_lborres text Lactate dehydrogenase (LDH) (U/L)
daily_cpk_lby radio Creatine Phosphokinase (CPK) available? 1, Yes ; 0, No ; 3, N/K
daily_cpkop_lbyn_2 dropdown Creatine Phosphokinase (CPK) < or > (optional) 1, < ; 2, >
daily_cpk_lbyn_2 text Creatine Phosphokinase (CPK) (U/L)
daily_creat_lbyn radio Creatinine available 1, Yes ; 0, No ; 3, N/K
daily_creatop_lborres dropdown Creatinine < or > (optional) 1, < ; 2, >
daily_creat_lborres text Creatinine
daily_creat_lborresu dropdown Creatinine Unit 1, μmol/L ; 2, mg/dL ; 3, umol/L
daily_sodium_lbyn radio Sodium available 1, Yes ; 0, No ; 3, N/K
daily_sodiumop_lborres dropdown Sodium < or > (optional) 1, < ; 2, >
daily_sodium_lborres text Sodium
daily_sodium_lborresu dropdown Sodium Unit 1, mmol/L ; 2, mEq/L
daily_potassium_lbyn radio Potassium available 1, Yes ; 0, No ; 3, N/K
daily_potassiumop_lborres dropdown Potassium < or > (optional) 1, < ; 2, >
daily_potassium_lborres text Potassium
daily_potassium_lborresu dropdown Potassium Unit 1, mmol/L ; 2, mEq/L
daily_procal_lbyn radio Procalcitonin available 1, Yes ; 0, No ; 3, N/K
daily_procalop_lborres dropdown Procalcitonin < or > (optional) 1, < ; 2, >
daily_procal_lborres text Procalcitonin (ng/mL)
daily_crp_lbyn radio C-reactive protein (CRP) available 1, Yes ; 0, No ; 3, N/K
daily_crpop_lborres dropdown C-reactive protein (CRP) < or > (optional) 1, < ; 2, >
daily_crp_lborres text C-reactive protein (CRP)
daily_crp_lborresu dropdown C-reactive protein (CRP) Unit 1, mg/L ; 2, mg/dL ; 3, ug/ml
daily_egfr_lbyn radio eGFR available 1, Yes ; 0, No ; 3, N/K
daily_egfrop_lborres dropdown eGFR < or > (optional) 1, < ; 2, >
daily_egfr_lborres text eGFR (mL/min/1.73 m2)
daily_egfr_equation checkbox eGFR equation/formula 1, daily_egfr_equation___1 CKD-EPI ; 2, daily_egfr_equation___2 MDRD ; 3, daily_egfr_equation___3 CG ; 4,  daily_egfr_equation___4 N/K
daily_hba1cop_lborres dropdown Most recent HbA1c < or > (optional) 1, < ; 2, >
daily_hba1c_lborres text Most recent HbA1c
daily_hba1c_lborresu dropdown Most recent HbA1c Unit 1, % ; 2, mmol/mol
daily_hba1c_lborresnk radio Most recent HbA1c N/K 1, N/K
daily_hba1c_lborresd text (date_dmy) Date of HbA1c
xray_prperf radio X-Ray/CT performed (this is chest X-ray if shorter CRF)? 1, Yes ; 2, No ; 3, N/A
infiltrates_faorres radio If yes, were infiltrates present? 1, Yes ; 2, No ; 3, N/A
daily_samples yesno Was a biological sample taken for research on this day? 1, Yes ; 0, No
daily_samples_kitno text If yes, please record the KIT number KIT NUMBER (first 3 characters should be CCP then
record 5 characters):
daily_form_complete Form Status dropdown Daily form section complete? 0, Incomplete ; 1, Unverified ; 2, Complete
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