Table 3.
Clinical minimum data set description for information exchange of coronavirus disease-19
| Required data elements | Real case definition | |||||
|---|---|---|---|---|---|---|
| Data classes/items | Content definition | Response format | Case sample | Vocabcode | Preferredcodes | Reference codes |
| D. Clinical presentation | ||||||
| Current existing condition | Hypertension Chronic respiratory diseases (specify type) | Select all that apply and string | Mild COPD | ICD10 | J44.8 | 313296004 |
| Diabetes | ||||||
| Coronary heart disease (specify type) | ||||||
| Cerebrovascular diseases (specify type) | ||||||
| Mental diseases (specify type) | ||||||
| Cancer (specify type) | ||||||
| HIV/AIDS infection | ||||||
| Renal diseases (specify type) | ||||||
| Liver disease | ||||||
| Other | ||||||
| Pregnancy status (if patient is a woman) | Force choice | Not pregnant | RCC | X76Qu | 60001007 | |
| Days from exposure to symptom onset | <2 days*, 2-4 days*, 4-7 days*, 1-2 weeks*, 2-4 weeks*, 1-3 months*, 3-6 months*, 6-12 months*, 1 year*< | Integer | 10 days | RCC | XaB8B | 307474000 |
| Days from illness onset to treatment | Integer | 2 days | RCC | XaB8B | 307474000 | |
| E. Exposure to casual factors | ||||||
| Exposure history | Contact/bitten with sick domestic or wild animal | Select all that apply and string | Contact with suspicious person outside wards | ICD10 CM | Z03.818 | 506901000000103 |
| Contact with suspicious person outside wards | ||||||
| Contact with patients in isolation wards | ||||||
| Contact with specimens | ||||||
| Exposure to contaminated surfaces Other | ||||||
| F. Physical examination | ||||||
| Body mass index (kg/m2) | <18.5*, between 18.5 and 24.9*, between 25 and 29.9*, >30*, unknown* | Force choice and integer | Body mass index 25-29, overweight | ICD10 | E66.9 | 162863004 |
| Respiratory rate | ≤24 breaths per min* >24 breaths per min* | Force choice and integer | 18 breath per minute | ICD10 | R06.89 | 289100008 |
| Temperature (°C) | <37.3*, 37.3-38*, 38.1-39*, >39.0* | Force choice and integer | Body temperature above 39 | ICD10 | R50.9 | 50177009 |
| Heart rate (bit/min) | <60*, between 60 and 100*, >100*, unknown* | Force choice and integer | Normal heart rate | RCC | Xa7s1 | 76863003 |
| Blood group | RH positive: A, B, AB, O RH negative: A, B, AB, O | Force choice and string | Blood group B Rh (D) positive | RCC | Xa0dT | 278150003 |
| Blood pressure (mmHg) | <120*, between 120 and 129*, between 130 and 139*, >140*, unknown* | Force choice and integer | Normal BP, 120-129 | RCC | Ua1fM | 2004005 |
| Lung examination | Clear or normal*, rales*, decreased breath sounds or dullness*, rhonchi*, wheezing*, other* | Select all that apply and string | Rhonchi present | ICD10 | R09.8 | 268929007 |
| G. Signs and symptoms | ||||||
| Asymptomatic | Yes*, no* | Force choice | Symptomatic disease | RCC | XC0v5 | 264931009 |
| If asymptomatic response is “NO,” the symptom is: | Fever Cough Dyspnea | Select all that apply and string | Dry cough Dyspnea Fever | ICD10 | R06.2 R06.8 R50.9 | 49727002 230145002 722892007 8579004 |
| weakness | Weakness | R11 | ||||
| Myalgia | ||||||
| Chest tightness or pain | ||||||
| Expectoration | ||||||
| Headache | ||||||
| Sore throat | ||||||
| Diarrhea | ||||||
| Anorexia | ||||||
| Nausea | ||||||
| Abdominal pain | ||||||
| Hemoptysis | ||||||
| Other | ||||||
| Symptom onset date | yyyy/mm/dd | Date | 2020/1/28 | RCC | XaR6r | 520191000000103 |
| H. Laboratory findings | ||||||
| Sample type | Nasopharyngeal swab | Select all that apply and | Nasopharyngeal swab | RCC | 412B | 168141000 |
| Oropharyngeal swab | string | |||||
| Broncho alveolar lavage | ||||||
| Nasopharyngeal aspirate | ||||||
| Sputum | ||||||
| Tissue (lung) biopsy | ||||||
| Serum | ||||||
| Whole blood test | ||||||
| Stool | ||||||
| Urine | ||||||
| Other | ||||||
| CBC | White blood cell count | Integer | CBC routine test | LOINC | 24317-0 | 26604007 |
| Lymphocyte count | ||||||
| Platelet count, hemoglobin Neutrophil count | ||||||
| Coagulation profiles | Prothrombin time APTT | Integer | Coagulation/bleeding tests normal | RCC | 42Q1 | 165562007 |
| D-dimer | ||||||
| Blood lipids and electrolytes | Triglyceride Total cholesterol | Integer | Serum triglycerides borderline high | RCC | 44Q3 44I2 | 442193004 166685005 |
| Low-density lipoprotein | Electrolytes normal | |||||
| Serum potassium | ||||||
| Serum sodium | ||||||
| Blood gases analysis | PaO2 | Integer | Normal blood gases | RCC | X7702 | 250544002 |
| PaO2/FiO2 | ||||||
| Lactic acid | ||||||
| PaCO | ||||||
| Liver and renal function | Creatinine Aspartate aminotransferase | Integer | Serum creatinine raised | ICD10 | R79.8 | 166717003 |
| Albumin | ||||||
| Alanine aminotransferase | ||||||
| Specialty LAB | Elisa test*, real-time PCR*, virus culture*, Other* | Select all that apply and string | Analysis using real time PCR | LOINC | 76581-8 | 444076003 |
| Sampling time | yyyy/mm/dd | Date | 2020/2/3 | RCC | 4I32 | 168149003 |
| Test time | yyyy/mm/dd | Date | 2020/2/4 | RCC | X77Vk | 252127002 |
| Sampling location | Nasal*, pharyngeal*, mouth*, lung*, blood vessel*, other* | Select all that apply and string | Nasopharyngeal | RCC | Xa0GE | 71836000 |
| Test result | Positive CoV*, negative CoV* | Force choice | Positive COVID-19 | ICD10 | R84.5 | 13320001000004109 |
| I. Imaging CT | ||||||
| Chest CT-scan | Unilateral*, bilateral* | Force choice | Bilateral chest CT-scan | ICD9 CM | 87.41 | 426827002 |
| CT features | GGO Consolidation interlobular septal thickening | Select all that apply and string | Lung consolidation | ICD10 | J18.1 | 95436008 |
| Crazy paving pattern | ||||||
| Air bronchogram | ||||||
| Spider web sign | ||||||
| Subpleuoral line | ||||||
| Bronchial wall thickening | ||||||
| Lymph node enlargement | ||||||
| Pericardial effusion | ||||||
| Plural effusion Other | ||||||
| Lung segment involvement | Average lung Dorsal of right lower | Select all that apply and | Right lower zone pneumonia | ICD10 | J18.1 | 301001009 |
| Lateral basal of right lower | string | |||||
| Posterior basal of right lower | ||||||
| Dorsal of left lower | ||||||
| Posterior basal of left lower | ||||||
| Other | ||||||
| Distribution | Sub pleural diffuse | Force choice | Pleural effusion | ICD10 | J11.1 | 81075000 |
| Per bronchial | ||||||
| Peri bronchovascular | ||||||
| Mixed | ||||||
| J. Treatment plan | ||||||
| Oxygen therapy | Noninvasive mechanical ventilator*, Invasive mechanical ventilator*, ECMO*, other* | Select all that apply and string | Noninvasive ventilation therapy | ICD9 CM | 93.90 | 784821000000105 |
| Drug therapy | Antibiotic treatment*, antifungal treatment*, antiviral treatment*, glucocorticoids*, intravenous immunoglobulin therapy*, other* | Select all that apply and string | Corticosteroid | RX- NORM | C0010137 | 79440004 |
| Complementary therapy | Yes*, no*, if yes, mention the procedure type* | Select all that apply and string | Respiratory rehabilitation | ICD9 CM | 93.99 | 790841000000106 |
| Consultation program | Mental*, occupational*, family*, social*, other* | Force choice | Mental counseling | ICD9 CM | 89.08 | 313080005 |
| K. Discharge outcome | ||||||
| Discharge date | yyyy/mm/dd | Date | 2020/2/9 | RCC | XaZuU | 442864001 |
| Discharge status | Death*, full recovery*, partial recovery*, other* | Force choice | Postdischarge follow-up | RCC | Xaat1 | 406151001 |
| If death, underlying cause of death | Related to current disease*, unrelated to current disease*, not applicable*, unknown* | Force choice | Not applicable | RCC | X90ca | 385432009 |
| If death, date of death | yyyy/mm/dd* | Date | Not applicable | RCC | X90ca | 385432009 |
| Discharge location | Home*, hospital*, other care facilities*: 1- quarantine centers, 2- nursing facility, 3- hospice care, 4-rehabilitation facility | Forced choice | Discharge to home | RCC | XaApt | 306689006 |
| Discharge Prescribed drugs | Drug name | String | Naproxen 200 mgtetracycline 250 mg | RX-NORM | C0027396 C0974349 | 416821000 324012004 |
| Date of follow up | yyyy/mm/dd | Date | 2020/2/14 | RCC | 8H8Z | 183616001 |
COPD=Chronic obstructive pulmonary disease, RCC=Renal cell carcinoma, BP=Blood pressure, CBC=Complete blood count, APTT=Activated partial thromboplastin time, PCR=Polymerase chain reaction, COVID=Coronavirus disease, CoV=Coronavirus, CT=Computed tomography, GGO=Ground-glass opacity, ECMO=Extracorporeal membrane oxygenation, LAB=Laboratory