Daily Form

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