After you submit the registration form, a link to the CTC Data Collection Menu - ExamExam form appears. You can also access the form by clicking Exam under Data Collection in the CTC Registry menu. 


Complete the form by selecting from among the options presented on the form and filling in the blank fields. Fields marked with an asterisk (*) must be entered or the form cannot be submitted. Specific instructions for each field are as follows:

 

Field Name

Description

Facility ID Number



Registry Case Number



Patient First Name



Patient Last Name



Exam Date

These fields are filled in automatically from the Case Registration form.

A. General Information

*Type of Study

Select the appropriate response.

*Referred from incomplete colonoscopy

Select the appropriate response.

*Interpreting Physician

The physician’s name must be selected from the drop-down list. For a physician to be listed as the interpreting physician, he or she must be listed as a CTC participant in the physician dictionary. Refer to Manage Physicians and Add Physicians to an Individual Registry for instructions on listing a physician as a CTC participant.

Physician UPIN



Physician NPI

These fields are filled in automatically from the physician directory.

*Patient’s Width (measured from scout at widest point)

Indicate the patient's width in centimeters at the widest point, as measured from the scanned projection radiogram (e.g. scout, surview, topogram or scanogram). Range: 5-70.

*Scanner Manufacturer

If the value you want to enter does not appear in the drop-down list, click Other. A field will appear in which you can enter the value. It must be 100 characters long or less.

*Detector Rows



*Detector Row Size (mm) (e.g. 8 x 1.25 -> 1.25; 16 x 0.75 -> 0.75)

If the value you want to enter does not appear in the drop-down list, click Other. A field will appear in which you can enter the value.

*CTDIvol

Enter the CTDIvol in mGy as displayed on the console. Range: 0.01 – 999.99.

*Slice Thickness



*Interval

If the value you want to enter does not appear in the drop-down list, click Other. A field will appear in which you can enter the value.

*IV Contrast

Indicate whether IV contrast was given.

*Supine image acquisition



*Prone image acquisition



*Decubitus image acquisition

Select the appropriate response.

B. Post Examination and Adverse Events

*At least one polyp >= 10 mm

Select the appropriate response. If Yes is selected then the Polyp form must be completed.

*Entire colon and rectum in scanned field of view

If Yes is selected then at least one reason must be indicated.

*Colonic perforation

If Yes is selected then etiology, location, and whether patient was symptomatic from perforation must be indicated.

*Clinically Significant Extracolonic Finding(s) (not otherwise known based on the history provided or based on a prior imaging procedure at the institution)

Select the appropriate response.

Name of Person Who Completed the Paper Form

Enter the name of the person who collected the data for this exam. If this name has not been previously entered in a case record, then enter the person’s first and last name. In the future, the name will appear in the drop-down list for this field. If the name has been previously entered, click the arrow and select it from the drop-down list.


Note: Please populate this field even if paper forms were not used; you may use the name of the person completing the on-line data submission

Name of person submitting form



Submission Date

These fields are filled in automatically.


Click the Submit button when the form is complete. You must correct any errors or the form will not be accepted by the registry. If no errors are detected a confirmation message appears and the case moves to Completed status. If a polyp of 10 millimeters or greater was detected during the exam, a link to the Polyp form appears.



 Previous: Case Registration Form