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Using controlled terminology and formatting from data collection through tabulation and analysis builds in traceability and transparency across study data. Controlled terminology and formats are required to be used as specified in this guide. General guidance for use of controlled terminology and formats is provided in this section with detailed instructions provided as part of sections specific to collection, tabulation, and analysis standards. TIG metadata and specifications refer to controlled terminology and formats defined both within and external to this guide. 


Controlled Terminology

CDISC Controlled Terminology and supporting documentation are managed as publications separate from this guide. Users of the TIG are encouraged to reference CDISC Controlled Terminology regularly to access controlled terms and for additional information. Controlled terminology is available via the CDISC website, https://www.cdisc.org/standards/terminology/controlled-terminology.

CDISC Controlled Terminology codelists are either extensible or non-extensible. For extensible codelists, new terms may be defined and used with the TIG if not already listed as either a CDISC Submission Value, a CDISC Synonym(s), or an NCI Preferred Term. Terms in non-extensible codelists must be used as-is and new terms cannot be added or used. When extending a codelist, the case-sensitivity convention of the codelist will be followed. It is highly recommended that new terms for extensible codelists be submitted to the National Cancer Institute (NCI) Enterprise Vocabulary Services (EVS) for review and possible inclusion in CDISC Controlled Terminology. Changes to existing terms and requests for new codelists can also be submitted to NCI-EVS for consideration. Submission of terminology requests to NCI-EVS is highly encouraged to ensure the consistency and transparency of data for all users of the TIG. Controlled terminology requests can be submitted to NCI-EVS by using the Term Suggestion form available at http://ncitermform.nci.nih.gov/ncitermform/?version=cdisc.

External sources for controlled terminology are referenced in this guide will be used as indicated in alignment with regulatory requirements.

To support implementation of standards, controlled terminology will be used to:

Standards for CollectionStandards for TabulationStandards for Analysis 
  • Ask specific questions on the CRF (e.g., Temperature)
  • Collect data values using terminology (e.g., Y or N)
  • Name variables in the operational database (e.g., TEMP for the collection of vital sign data when a unique variable name must be created for each vital sign result).
  • Name domain datasets and variables in datasets when applicable.
  • Represent collected, assigned, and derived values in datasets. 


  • Represent the level of imputation for numeric date/time variables.
  • Represent the subject status at different phases of the trial.
  • Represent the derivation method for cases of data imputation.
  • Represent values for analysis concepts as applicable.

Formats

Standards for tabulation and analysis require representation of dates and/or times, intervals of time, and durations of time in ISO 8601 format as defined by the International Organization for Standardization (ISO) (http://www.iso.org). The appropriate date and/or time ISO format must be used when specified. Additional ISO formats are referenced in this guide will be used as indicated in alignment with regulatory requirements.

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