# OpenScar Case Abstraction Form

Use this form to convert one retrospective scar or keloid case into the OpenScar six-table schema. It is a human-facing checklist, not a substitute for clinical judgment or institutional governance.

Do not enter direct identifiers in this form.

## Case Setup

- Abstractor:
- Reviewer:
- Abstraction date:
- Source record type:
- Governance status:
- Notes requiring reviewer attention:

## Patient Table

Target file: `data/templates/patient.csv`

- `patient_id`:
- `sex_at_birth`:
- `age_at_first_visit`:
- `fitzpatrick_skin_type`:
- `relevant_history`:
- `comorbidities`:
- `consent_status`:

Reviewer check:

- Direct identifiers removed:
- Consent or research export status clear:
- Age recorded without date of birth:

## Lesion Table

Target file: `data/templates/lesion.csv`

- `lesion_id`:
- `patient_id`:
- `scar_category`:
- `anatomic_site`:
- `laterality`:
- `presumed_trigger`:
- `onset_date_precision`:
- `duration_months_at_baseline`:
- `baseline_symptoms`:

Reviewer check:

- Scar category supportable from clinical note:
- Anatomic site specific enough for analysis:
- Multiple lesions separated into distinct `lesion_id` values:

## Visit Table

Target file: `data/templates/visit.csv`

Repeat for each visit.

- `visit_id`:
- `patient_id`:
- `lesion_id`:
- `visit_date_offset_days`:
- `visit_type`:
- `clinician_assessment`:
- `patient_reported_pain`:
- `patient_reported_itch`:
- `patient_satisfaction`:
- `validated_scale_name`:
- `validated_scale_score`:

Reviewer check:

- Baseline visit is offset day 0:
- Follow-up timing converted to day offsets:
- Symptoms recorded as missing rather than inferred when unavailable:

## Image Table

Target file: `data/templates/image.csv`

Repeat for each approved image pointer.

- `image_id`:
- `visit_id`:
- `lesion_id`:
- `image_uri`:
- `view_label`:
- `capture_device`:
- `distance_cm`:
- `scale_marker_present`:
- `color_reference_present`:
- `lighting_quality`:
- `angle_quality`:
- `focus_quality`:
- `privacy_redaction_status`:

Reviewer check:

- Image pointer does not expose direct identifiers:
- Privacy redaction reviewed:
- Lighting, angle, focus, scale marker, and color reference marked conservatively:

## Treatment Table

Target file: `data/templates/treatment.csv`

Repeat for each intervention exposure.

- `treatment_id`:
- `visit_id`:
- `lesion_id`:
- `treatment_modality`:
- `treatment_detail`:
- `combination_flag`:
- `adverse_event_reported`:
- `adverse_event_detail`:

Reviewer check:

- Dose, device, protocol, or technique captured when present:
- Combination treatment marked explicitly:
- Adverse event fields left conservative and source-grounded:

## Outcome Table

Target file: `data/templates/outcome.csv`

- `outcome_id`:
- `lesion_id`:
- `assessment_visit_id`:
- `follow_up_days_from_baseline`:
- `response_category`:
- `recurrence_status`:
- `recurrence_definition`:
- `functional_impact`:
- `cosmetic_impact`:
- `outcome_confidence`:

Reviewer check:

- Outcome label is tied to a visit:
- Recurrence definition is stated when recurrence is assessed:
- Outcome confidence reflects source quality:

## Missingness Notes

Use this section to record fields that were unavailable in the retrospective record and should be captured prospectively.

| Field | Missing reason | Prospective fix |
| --- | --- | --- |
|  |  |  |

## Case Completion

- Six-table rows complete:
- Reviewer sign-off:
- Ready for de-identified registry merge:
- Needs schema extension: