santa clara county trauma registry data dictionary · santa clara county trauma registry data...

Santa Clara County Trauma Registry Data Dictionary

2017 1

County of Santa Clara

Emergency Medical Services Agency

Trauma System

Data Dictionary

2017

Incorporating:

National Trauma Data Standards

(NTDS 2017 Admissions Data Dictionary)

California State Trauma (CEMSIS) Data Dictionary

Final Version 02/02/2017


2017 2

TABLE OF CONTENTS

SANTA CLARA COUNTY PATIENT INCLUSION CRITERIA 11

NTDB PATIENT INCLUSION CRITERIA 12

STATE OF CALIFORNIA PATIENT INCLUSION CRITERIA 13

COMMON NULL VALUES 14

DATE AND TIME VALUES 15

DEMOGRAPHIC INFORMATION

TRAUMA CENTER CODE 17

TRAUMA REGISTRY NUMBER 18

ED/HOSPITAL ARRIVAL DATE 19

HOSPITAL ACCOUNT NUMBER 20

MEDICAL RECORD NUMBER 21

LAST NAME 22

FIRST NAME 23

MIDDLE INITIAL 24

ALIAS LAST NAME 25

ALIAS FIRST NAME 26

DATE OF BIRTH 27

AGE 28

AGE UNITS 29

SEX 30

RACE 31

ETHNICITY 32

SOCIAL SECURITY NUMBER 33

PATIENT’S HOME ZIP/POSTAL CODE 34

PATIENT’S HOME CITY 35

PATIENT’S HOME COUNTY 36

PATIENT’S HOME STATE 37


2017 3

PATIENT’S HOME COUNTRY 38

ALTERNATE HOME RESIDENCE 39

ADMITTING SERVICE 40

ADMITTING PHYSICIAN 41

ABSTRACTOR 42

ABSTRACT DATE 43

DATA ENTRY DATE 44

PREHOSPITAL INFORMATION

NAME 46

HOSPITAL ARRIVAL DATE 47

TRAUMA REGISTRY NUMBER 48

TRANSPORT MODE 49

OTHER TRANSPORT MODE 50

TYPE OF TRANSPORT 51

AGENCY 52

PCR Y/N 53

PCR # 54

EMS DISPATCH DATE 55

EMS DISPATCH TIME 56

EMS UNIT ARRIVAL DATE AT SCENE OR TRANSFERRING FACILITY 57

EMS UNIT ARRIVAL TIME AT SCENE OR TRANSFERRING FACILITY 58

EMS UNIT ARRIVAL TIME AT PATIENT 59

EMS UNIT DEPARTURE DATE FROM SCENE OR TRANSFERRING FACILITY 60

EMS UNIT DEPARTURE TIME FROM SCENE OR TRANSFERRING FACILITY 61

EMS UNIT DESTINATION TIME 62

EMS UNIT RESPONSE TIME 63

EMS UNIT SCENE TIME 64

EMS UNIT TRANSPORT TIME 65


2017 4

TRAUMA CENTER CRITERIA 66

PREHOSPITAL CARDIAC ARREST 68

PREHOSPITAL PROCEDURES 69

TRANSPORT TYPE 70

VITAL SIGNS DATE 71

VITAL SIGNS TIME 72

INITIAL FIELD PULSE RATE 73

INITIAL FIELD RESPIRATORY RATE 74

INITIAL FIELD RESPIRATORY RATE QUALIFIER 75

INITIAL FIELD OXYGEN SATURATION 76

INITIAL FIELD SYSTOLIC BLOOD PRESSURE 77

INITIAL FIELD DIASTOLIC BLOOD PRESSURE 78

INITIAL FIELD GCS - EYE 79

INITIAL FIELD GCS - MOTOR 80

INITIAL FIELD GCS - VERBAL 81

INITIAL FIELD GCS - TOTAL 82

INITIAL FIELD GCS QUALIFIER 83

INITIAL FIELD REVISED TRAUMA SCORE 84

INJURY INFORMATION

INJURY INCIDENT DATE 86

INJURY INCIDENT TIME 87

ICD-10 PLACE OF OCCCURENCE EXTERNAL CAUSE CODE 88

INCIDENT LOCATION ZIP/POSTAL CODE 89

INCIDENT CITY 90

INCIDENT COUNTY 91

INCIDENT STATE 92

INCIDENT COUNTRY 93

INJURY TYPE 94


2017 5

CAUSE OF INJURY 95

WORK-RELATED 96

PATIENT’S OCCUPATIONAL INDUSTRY 97

PATIENT’S OCCUPATION 98

FALL HEIGHT (FT) 100

ICD-10 PRIMARY EXTERNAL CAUSE CODE 101

ICD-10 ADDITIONAL EXTERNAL CAUSE CODE 102

PATIENT LOCATION IN VEHICLE 103

PROTECTIVE DEVICES 104

INCIDENT COMMENTS 106

CHILD SPECIFIC RESTRAINT 107

AIRBAG DEPLOYMENT 108

REPORT OF PHYSICAL ABUSE 109

INVESTIGATION OF PHYSICAL ABUSE 110

CAREGIVER AT DISCHARGE 111

REFER IN INFORMATION

DATE OF ARRIVAL 113

TIME OF ARRIVAL 114

DATE OF DISCHARGE 115

TIME OF DISCHARGE 116

LENGTH OF STAY 117

PATIENT MODE OF ARRIVAL 118

REFERRING FACILITY 119

REFERRING HOSPITAL COMMENTS 121

TRANSFERRED IN 122

DIRECT ADMIT 123




2017 6

ADMIT LOCATION 126

TRANSFER IN FOR HIGHER LEVEL OF CARE 127

EMERGENCY DEPARTMENT INFORMATION

ED/HOSPITAL ARRIVAL DATE 129

ED/HOSPITAL ARRIVAL TIME 130

ED DISCHARGE DATE 131

ED DISCHARGE TIME 132

ED LENGTH OF STAY 133

ED PHYSICIAN 134



ED DISCHARGE DISPOSITION 137

SIGNS OF LIFE 138

VITAL SIGNS DATE 139

VITAL SIGNS TIME 140

INITIAL ED/HOSPITAL PULSE RATE 141

INITIAL ED/HOSPITAL RESPIRATORY RATE 142

INITIAL ED/HOSPITAL RESPIRATORY ASSISTANCE 143

INITIAL ED/HOSPITAL OXYGEN SATURATION 144

INITIAL ED/HOSPITAL SUPPLEMENTAL OXYGEN 145

INITIAL ED/HOSPITAL SYSTOLIC BLOOD PRESSURE 146

INITIAL ED/HOSPITAL DIASTOLIC BLOOD PRESSURE 147

INITIAL ED/HOSPITAL GCS - EYE 148

INITIAL ED/HOSPITAL GCS -VERBAL 149

INITIAL ED/HOSPITAL GCS - MOTOR 150

INITIAL ED/HOSPITAL GCS -TOTAL 151

INITIAL ED/HOSPITAL GCS ASSESSMENT QUALIFIERS 152

INITIAL ED/HOSPITAL HEIGHT 153


2017 7

INITIAL ED/HOSPITAL WEIGHT 154

INITIAL ED/HOSPITAL REVISED TRAUMA SCORE 155

INITIAL ED/HOSPITAL TEMPERATURE 156

DRUG SCREEN 157

ALCOHOL SCREEN 158

ALCOHOL SCREEN RESULTS 159

INTERVENTIONS 160

ED COMMENTS 161

TIME TO FIRST CT SCAN 162

TRAUMA TEAM INFORMATION

ACTIVATION LEVEL 164

ACTIVATION DATE 165

ACTIVATION TIME 166

ROLE 167

MEMBER ID 168

LONG NAME 169

PATIENT ARRIVED 170

TRAUMA MEMBER ARRIVED 171

RESPONSE TIME 172

TIMELY 173

CONSULTS INFORMATION

DATE CALLED 175

TIME CALLED 176

DATE RESPONDED 177

TIME RESPONDED 178

SERVICE 179

PHYSICIAN 180

LABORATORY INFORMATION


2017 8

TESTING DONE 182

TOXICOLOGY 183

INPATIENT INFORMATION

LOCATION 185

DATE IN 186

TIME IN 187

DATE OUT 188

TIME OUT 189

LENGTH OF STAY 190

VENT DAYS 191

ICU INITIAL TEMPERATURE 193

TOTAL ICU LENGTH OF STAY 194

NON-ICU VENTILATOR DAYS 196

ICU VENTILATOR DAYS 197

TOTAL VENTLATOR DAYS 198

HOSPITAL PROCEDURE INFORMATION

LOCATION 201

OR# 202

HOSPITAL PROCEDURE START DATE 203

HOSPITAL PROCEDURE START TIME 204

ELAPSED TIME 205

ICD-10 HOSPITAL PROCEDURES 206

ICD-10 HOSPITAL PROCEDURES TEXT 208

MD CODE 209

MD LONG NAME 210

SERVICE 211

ELAPSED TIME TO PROCEDURE 212

BLOOD PRODUCTS 213


2017 9

FIRST OR TEMPERATURE 214

TEMPERATURE UNITS 215

TIME TO FIRST OR VISIT 216

STUDY 217

BODY PART 218

RESULTS 219

CO-MORBIDITIES INFORMATION

CO-MORBID CONDITIONS 221

DIAGNOSIS INFORMATION

ICD-10 INJURY DIAGNOSES 224

AIS PREDOT CODE 225

AIS SEVERITY 226

ISS LOCAL 227

ISS BODY REGION 228

INJURY ICD-10 DX TEXT 229

DISCHARGE INFORMATION

HOSPITAL DISCHARGE DATE 231

HOSPITAL DISCHARGE TIME 232

LENGTH OF STAY 233

HOSPITAL DISCHARGE DISPOSITION 234

LIVE/DIE 236

REASON FOR TRANSFER 237

TRANSFER TO HOSPITAL 238

TRANSFER OUT FOR HIGHER LEVEL OF CARE 240

REPATRIATION? 241

PRIMARY METHOD OF PAYMENT 242

TOTAL HOSPITAL CHARGES 243

DEATH INFORMATION


2017 10

DEATH LOCATION 245 ORGAN/TISSUE DONATION REFERRAL 246

FAMILY APPROACHED 247

ORGAN/TISSUE DONATION CONSENT 248

AUTOPSY 249

AUTOPSY TYPE 250

AUTOPSY ID 251

ORGAN/TISSUES PROCURED 252

SURGEON SPECIFIC REPORTING

NATIONAL PROVIDER IDENTIFIER (NPI) 254

QUALITY ASSURANCE INFORMATION

COMPLICATIONS 256

APPENDIX 3: GLOSSARY OF TERMS 273


2017 11

SANTA CLARA COUNTY TRAUMA SYSTEM

TRAUMA REGISTRY PATIENT INCLUSION CRITERIA

The Santa Clara County Trauma System collects data on those patients that have suffered life-threatening or potentially life-threatening injuries and are transported to a designated trauma center for definitive care. The following criteria help to quantify the trauma center’s service volume and assists in monitoring injury control. Patients included have been transported to the trauma center because they met Santa Clara County EMS Field Triage criteria (regardless of ED Destination status) or are admitted as a trauma patient due to injury, or have been transferred from another facility for definitive care.

Section 1797.199 of the California Health and Safety Code includes the following:

(k) by October 31, 2001, the authority shall develop criteria for the standardized reporting of trauma patients to local trauma registries, The authority shall utilize the trauma patient criteria for reporting trauma patients to local trauma registries by July 1, 2003

To that end, all local EMS Agencies shall utilize the minimum trauma patient criteria for reporting trauma patients to local trauma registries. It is not the intent of the Santa Clara County EMS Agency to hinder or restrict trauma data collected internally at each trauma center. Instead, the intent is to clearly define the criteria for standardized reporting of trauma patients to the local EMS Agency trauma registry as required by CA legislation.

CRITERIA

1. Any patients with an ICD10 Discharge diagnosis as defined by the National Trauma Data Standard Patient Inclusion Criteria or meets prehospital trauma triage criteria

AND 2. Physically evaluated by trauma or burn surgeon in the ED or resuscitation area

OR 3. All patient identified by the trauma service that have sustained a traumatic injury and

were not identified in Prehospital or the ED OR

4. All deaths due to traumatic injury OR

5. Transfers intra or interfacility for Trauma Services. Trauma Services may include but not be limited to trauma surgery, neurosurgery, and orthopedics. Intrafacility transfers would include trauma consults by a member of the trauma service.

Excluding:

1. Hangings/asphyxiation with no other traumatic injuries. 2. Isolated Burns with no other traumatic injuries, (This is the only exclusion in the State

required minimum inclusion criteria). 3. Poisoning with no other traumatic injuries. 4. Drowning with no other traumatic injuries. 5. Elderly (>65 years old) hip fractures

There is a subset of trauma patients included in the SCC trauma registry that did not have a trauma ICD9 code assigned due to no identified injuries, This patient population is included because they met trauma triage criteria and utilized trauma center resources, which will allow for identification of over triaged patients.


2017 12

National Trauma Data Standard Patient Inclusion Criteria

Definition:

To ensure consistent data collection across States into the National Trauma Data Standard, a

trauma patient is defined as a patient sustaining a traumatic injury and meeting the following

criteria:

At least one of the following injury diagnostic codes defined as follows:

International Classifcation of Diseases, Tenth Revision (ICD-10-CM):

S00-S99 with 7th character modifiers of A, B, or C ONLY. (Injuries to specific body parts –

initial encounter)

T07 (unspecified multiple injuries)

T14 (injury of unspecified body region)

T20-T28 with 7th character modifier of A ONLY (burns by specific body parts – initial

encounter)

T30-T32 (burn by TBSA percentages)

T79.A1-T79.A9 with 7th character modifier of A ONLY (Traumatic Compartment Syndrome –

initial encounter)

Excluding the following isolated injuries:

ICD-10-CM:

S00 (Superficial injuries of the head)

S10 (Superficial injuries of the neck)

S20 (Superficial injuries of the thorax)

S30 (Superficial injuries of the abdomen, pelvis, lower back and external genitals)

S40 (Superficial injuries of shoulder and upper arm)

S50 (Superficial injuries of elbow and forearm)

S60 (Superficial injuries of wrist, hand and fingers)

S70 (Superficial injuries of hip and thigh)

S80 (Superficial injuries of knee and lower leg)

S00 (Superficial injuries of ankle, foot and toes)

Late effect codes, which are represented using the same range of injury diagnosis codes but with

the 7th digit modifier code of D through S, are also excluded.

AND MUST INCLUDE ONE OF THE FOLLOWING IN ADDITION TO

(ICD-10-CM S00-S99, T07, T14, T20-T28, T30-T32 and T79.A1-T79.A9):

Hospital admission as defined by your trauma registry inclusion criteria; OR Patient transfer via EMS transport (including air ambulance) from one hospital to another hospital;

OR Death resulting from the traumatic injury (independent of hospital admission or hospital transfer

status)


2017 13

State of California Trauma Dataset Patient Inclusion Criteria

Definition:

To ensure consistent data collection across California and into the National Trauma

Registry, a trauma patient is defined as a patient sustaining a traumatic injury and

meeting the following criteria:

The State criteria is consistent with the National Trauma Data Standards.


2017 14

COMMON NULL VALUES SCC County Element State Element National Element

Definitions:

These values are to be used with each of the data elements described in this document which have been defined to accept the Null Values.

Field Values:

1. Not Applicable NA 2. Not Documented ND (Equivalent to NTDB = Not Known/Not Recorded)

Additional Information

For any collection of data to be of value and reliably represent what was intended, a strong commitment must be made to ensure the correct documentation of incomplete data. When data elements associated with the National Trauma Data Standard are to be electronically stored in a database or moved from one database to another using XML, the indicated null values should be applied.

1. Not Applicable: This null value code applies if, at the time of patient care documentation, the information requested was “Not Applicable” to the patient, the hospitalization or the patient care event. For example, variables documenting EMS care would be “Not Applicable” if a patient self-transports to the hospital.

2. Not Documented: This null value applies if hospital documentation of an information system has an empty field or nothing is recorded. This null value signifies that the hospital patient care record provides a “place holder” to document the specific data element but that no value for that element was recorded for the patient. For example, a hospital patient care record may request the date of birth but none was recorded. This is equivalent to NTDB = Not Known/Not Recorded.


2017 15

DATE AND TIME VALUES SCC County Element State Element National Element

Definitions:

These values are to be used with each of the data elements described in this document which have been defined to accept the Date and Time Values.

Field Values:

Date Collected as MM-DD-YYYY.

Time Collected as HHMM (military time).


2017 16

DEMOGRAPHIC INFORMATION


2017 17

DEMOGRAPHIC INFORMATION SCC County Element D_01 State Element N/A TRAUMA CENTER CODE National Element N/A

Definition This number is assigned to each participating facility that collects trauma data. This facility number is assigned by the Santa Clara County EMS Agency.

Field Values

15 Stanford Hospital and Clinics

20 Santa Clara Valley Medical Center

30 Regional Medical Center of San Jose


Auto-populated as a read-only field - no user action necessary.

Data Source Hierarchy

Associated Edit Checks

Rule ID Level Message

0001 1 Invalid value

0002 2 Field cannot be blank

Data format: [character, 2] single entry Picklist: Yes, non-modifiable Min. Value: N/A Max. Value: N/A Accepts Null Value: No


2017 18

DEMOGRAPHIC INFORMATION SCC County Element D_02 State Element N/A TRAUMA REGISTRY NUMBER National Element N/A

Definition The number assigned to each trauma patient by the trauma center.

Field Values

Institution number - Admit month - Registry assigned patient # - Year Example: 20-04-001-07 = VMC – “April” = Admit Month - 001 = Registry assigned patient # - Year is “2007”

Additional Information Data Source Hierarchy Associated Edit Checks




Data format: [character,12] auto-populated Pick-list: No Min. Value: N/A Max. Value: N/A Accepts Null Value: No


2017 19

DEMOGRAPHIC INFORMATION SCC County Element D_03 State Element ED_01 ED/HOSPITAL ARRIVAL DATE National Element ED_01

Definition The date the patient arrived to the ED/hospital. Field Values

Relevant value for data element Additional Information

If the patient was brought to the ED, enter the date the patient arrived in the ED. If patient was directly admitted to the hospital, enter the date the patient was admitted to the hospital.

Used to auto-generate additional calculated field: Total Length of Hospital Stay (elapsed time from ED/Hospital Arrival to ED/Hospital Discharge).


1. ED Record 2. Billing Sheet/Medical Records Coding Summary Sheet 3. Hospital Discharge Summary



0005 1 Date is not valid

0006 1 Date out of range


0008 2 Field cannot be Not Known/Not Recorded

0009 3 ED/Hospital Arrival Date is earlier than EMS Dispatch Date

0010 3 ED/Hospital Arrival Date is earlier than EMS Unit Arrival on Scene Date

0011 3 ED/Hospital Arrival Date is earlier than EMS Unit Scene Departure Date

0012 2 ED/Hospital Arrival Date is later than ED Discharge Date

0013 2 ED/Hospital Arrival Date is later than Hospital Discharge Date

0014 3 ED/Hospital Arrival Date is earlier than Date of Birth

0015 3 ED/Hospital Arrival Date should be after 1993

0016 3 ED/Hospital Arrival Date minus Injury Incident Date should be less than 30 days

0017 3 ED/Hospital Arrival Date minus EMS Dispatch Date is greater than 7 days

0018 2 Field cannot be Not Applicable

Data format: [DATE] single entry Pick-list: No Min. Value: 01/01/2008 Max. Value: current date Accepts Null Value: Yes


2017 20

DEMOGRAPHIC INFORMATION SCC County Element D_04 State Element N/A HOSPITAL ACCOUNT NUMBER National Element N/A

Definition The patient’s account number assigned by the facility treating the trauma.

Field Values

Relevant for the data element


User-defined patient visit record identifier


1. Hospital Face sheets 2. ED Records 3. Billing sheet/Medical Records Coding summary





Data format: [character, 15] single entry Pick-list: No Min. Value: N/A Max. Value: N/A Accepts Null Value: Yes


2017 21

DEMOGRAPHIC INFORMATION SCC County Element D_05 State Element N/A MEDICAL RECORD NUMBER National Element N/A

Definition The patient’s medical record number as assigned by the facility treating the trauma.

Field Values

Relevant for the data element


User-defined patient visit record identifier.


1. Face sheets 2. ED Records 3. Billing sheet/Medical Records Coding summary







2017 22

DEMOGRAPHIC INFORMATION SCC County Element D_06 State Element N/A LAST NAME National Element N/A

Definition Patient’s last name.

Field Values

Relevant value for data element



1. Billing Sheet/Medical Records Coding Summary Sheet 2. ED Nurses Notes 3. Triage Form/Trauma Flow Sheet 4. EMS Report Form 5. ED Admission Form







2017 23

DEMOGRAPHIC INFORMATION SCC County Element D_07 State Element N/A FIRST NAME National Element N/A

Definition Patient’s first name.

Field Values




1. Billing Sheet/Medical Records Coding Summary Sheet 2. ED Nurses Notes 3. Triage Form/.Trauma Flow Sheet 4. EMS Report Form 5. ED Admission Form







2017 24

DEMOGRAPHIC INFORMATION SCC County Element D_08 State Element N/A MIDDLE INITIAL National Element N/A

Definition Patient’s middle initial.

Field Values











2017 25

DEMOGRAPHIC INFORMATION SCC County Element D_09 State Element N/A ALIAS LAST NAME National Element N/A

Definition Other last name used by patient. May also be used when name is unknown.

Field Values











2017 26

DEMOGRAPHIC INFORMATION SCC County Element D_10 State Element N/A ALIAS FIRST NAME National Element N/A

Definition Other first name used by patient. May also be used when name is unknown.

Field Values











2017 27

DEMOGRAPHIC INFORMATION SCC County Element D_11 State Element D_07 DATE OF BIRTH National Element D_07

Definition The patient’s date of birth.

Field Values



If Date of Birth is “Not Known/Not Recorded”, complete variables: Age and Age Units.

If Date of Birth equals Injury Date, then the Age and Age Units variables must be completed.

Used to calculate patient age in minutes, hours, days, months, or years.








0036 3 Field should not be Not Known/Not Recorded

0037 2 Date of Birth is later than EMS Dispatch Date

0038 2 Date of Birth is later than EMS Unit Arrival on Scene Date

0039 2 Date of Birth is later than EMS Unit Scene Departure Date

0040 2 Date of Birth is later than Injury Date

0041 2 Date of Birth is later than ED Discharge Date

0042 2 Date of Birth is later than Hospital Discharge Date

0043 2 Date of Birth + 120 years must be less than Injury Date


Data format: [date] single entry Pick-list: No Min. Value: Date minus 120 yrs Max. Value: Current Date Accepts Null: Yes


2017 28

DEMOGRAPHIC INFORMATION SCC County Element D_12 State Element D_08 AGE National Element D_08

Definition The patient’s age at the time of injury (best approximation).

Field Values

Relevant data for the data element




If Date of Birth equals ED/Hospital Arrival Date, then the Age and Age Units variables must be completed.

Must also complete variable: Age Units.

Normally calculated from date of birth and auto-populated.


1. Face sheet 2. ED Records 3. History and Physical 4. Billing Sheet/Medical Records Coding Summary Sheet 5. EMS Report Form



0045 1 Age is outside the valid range of 0 - 120


0047 3 Injury Date minus Date of Birth should equal submitted Age as expressed in the Age Units specified.

0048 4 Age is greater than expected for the Age Units specified. Age should not exceed 60 minutes, 24 hours, 30 days, 24 months or 120 years. Please verify this is correct.

0049 2 Field must be Not Applicable when Age Units is Not Applicable

0050 2 Field must be Not Known/Not Recorded when Age Units is Not Known/Not Recorded

Data format: [Number, 3] single entry Pick-list: No Min. Value: 1 Max. Value: 120 Accepts Null: Yes


2017 29

DEMOGRAPHIC INFORMATION SCC County Element D_13 State Element D_09 AGE UNITS National Element D_09

Definition The units used to document the patient’s age (Minutes, Hours, Days, Months, Years).

Field Values

I (Minutes) ME (Minutes Estimated)

H (Hours) HE (Hours Estimated)

D (Days) DE (Days Estimated)

M (Months) ME (Months Estimated)

Y (Years) YE (Years Estimated)


Normally calculated from date of birth and auto-populated. (SCC)



If Date of Birth equals ED/Hospital Arrival Date, then the Age and Age Units variables must be completed.

Must also complete variable: Age.


1. ED Nurses’ Notes 2. EMS Report Form 3. Triage Form/Trauma Flow Sheet 4. Billing sheet/Medical Records Coding Sheet 5. ED Admission form



0051 1 Value is not a valid menu option


0053 2 Field must be Not Applicable when Age is Not Applicable

0054 2 Field must be Not Known/Not Recorded when Age is Not Known/Not Recorded

Data format: [Character, 1] single entry Pick-list: Yes, non-modifiable Min. Value: NA Max. Value: NA Accepts Null: Yes


2017 30

DEMOGRAPHIC INFORMATION SCC County Element D_14 State Element D_12 SEX National Element D_12

Definition The patient’s sex.

Field Values

M (MALE)

F (FEMALE)


Patients who have undergone a surgical and/or hormonal sex reassignment should be coded using the current assignment.


1. Face Sheet 2. ED Records 3. History and Physical 4. EMS Report Form








2017 31

DEMOGRAPHIC INFORMATION SCC County Element D_15 State Element D_10 RACE National Element D_10

Definition The patient’s race.

Field Values

I American Indian

A Asian

B Black or African American

N Native Hawaiian/Pacific Islander

W White

O Other


Patient race should be based upon self-report or identified by a family member.

The maximum number of races that may be reported for an individual patient is 2.

Based on the 2010 US Census Bureau.


1. ED Records 2. EMS Report form 3. History and Physical





0060 2 Field cannot be Not Applicable (US only)

0061 2 Field must be Not Applicable (non-US)



2017 32

DEMOGRAPHIC INFORMATION SCC County Element D_16 State Element D_11 ETHNICITY National Element D_11

Definition The patient’s ethnicity.

Field Values

H Hispanic or Latino

N Non-Hispanic or Latino


Patient ethnicity should be based upon self-report or identified by a family member.

The maximum number of ethnicities that may be reported for an individual patient is 1.

Based on the 2010 US Census Bureau.


1. ED Records 2. EMS Report form 3. History and Physical





0064 2 Field cannot be Not Applicable (US only)

0065 2 Field must be Not Applicable (non-US)



2017 33

DEMOGRAPHIC INFORMATION SCC County Element D_17 State Element NA SOCIAL SECURITY NUMBER National Element NA

Definition Number used in patient identification.

Field Values

Last digits of SSN


Document “NA” if SSN is unavailable.


1. Face Sheet 2. Billing Sheet 3. EMS Report form





Data format: [Character, 5] single entry Pick-list: No Min Value: 0 Max Value: 9 Accepts Null: Yes


2017 34

DEMOGRAPHIC INFORMATION SCC County Element D_18 State Element D_01 PATIENT’S HOME ZIP/POSTAL CODE National Element D_01

Definition The patient’s home ZIP/Postal code of primary residence.

Field Values



Can be stored as a 5 or 9 digit code (XXXXX-XXXX) for US and CA, or can be stored in the postal code format of the applicable country.

May require adherence to HIPAA regulations.

If the only address provided is a PO Box, enter the ZIPCODE of the PO BOX. (SCC)

Homeless = NA. (SCC)

Foreign Visitor = NA. (SCC)

If ZIP/Postal code is “Not Applicable,” complete variable: Alternate Home Residence.

If ZIP/Postal code is “Not Recorded/Not Known,” complete variables: Patient’s Home Country, Patient’s Home State (US only), Patient’s Home County (US only) and Patient’s Home City (US only).

If ZIP/Postal code is known, must also complete Patient’s Home Country.


1. ED Records 2. EMS Report form





Data format: [Character, 5] single entry Pick-list: No Min. Value: 0 Max. Value: 9 Accepts Null: Yes


2017 35

DEMOGRAPHIC INFORMATION SCC County Element D_19 State Element D_05 PATIENT’S HOME CITY National Element D_05

Definition The patient’s city (or township, or village) of residence.

Field Values

Relevant value for data element (five digit numeric FIPS code)


Only completed when ZIP/Postal code is “Not Recorded/Not Known” and country is US.

If the Zip Code doesn’t match the patient’s home City provided, manually override the information and enter the correct City. (SCC)

Used to calculate FIPS Code.

The null value “Not Applicable” is used if Patient’s Home Zip/Postal Code is reported.


1 Face Sheet 2 Billing Sheet/Medical Records Coding Summary Sheet 3 ED Records 3. EMS Report form



0070 1 Invalid value (US only)

0071 2 Field cannot be blank (US only)

0072 2 Field must be Not Applicable (Non-US)

Data format: [Character,15] single entry Pick-list: No Min. Value: 0 Max. Value: 9 Accepts Null: Yes


2017 36

DEMOGRAPHIC INFORMATION SCC County Element D_20 State Element D_04 PATIENT’S HOME COUNTY National Element D_04

Definition The patient’s county (or parish) of primary residence

Field Values

Relevant value for data element (three digit numeric FIPS code)






4. Face Sheet 5. Billing Sheet/Medical Records Coding Summary Sheet 6. ED Records 4. EMS Report form






Data format: [Character,15] single entry Pick-list: No Min. Value: 0 Max. Value: 9 Accepts Null: Yes


2017 37

DEMOGRAPHIC INFORMATION SCC County Element D_21 State Element D_03 PATIENT’S HOME STATE National Element D_03

Definition The state (territory, province, or District of Columbia) where the patient resides.

Field Values

Relevant value for data element (two digit numeric FIPS code)






1 Face Sheet 2 Billing Sheet/Medical Records Coding Summary Sheet 3 EMS Report form






Data format: [Character,2] single entry Pick-list: Yes Min. Value: 0 Max. Value: 9 Accepts Null: No


2017 38

DEMOGRAPHIC INFORMATION SCC County Element D_22 State Element D_02 PATIENT’S HOME COUNTRY National Element D_02

Definition The country where the patient resides.

Field Values

Relevant value for data element (two digit alpha country code)


Values are two character FIPS codes representing the country (e.g., US).

If Patient’s Home Country is not US, then the null value “Not Applicable” is used for: Patient’s Home State, Patient’s Home County, and Patient’s Home City.


4 Face Sheet 5 Billing Sheet/Medical Records Coding Summary Sheet 6 EMS Report form






0082 2 Field cannot be Not Known/Not Recorded when Home Zip is not: (1) blank, (2) Not Applicable, or (3) Not Known/Not Recorded

Data format: [Character,2] single entry Pick-list: Yes Min. Value: 0 Max. Value: 9 Accepts Null: No


2017 39

DEMOGRAPHIC INFORMATION SCC County Element D_23 State Element D_06 ALTERNATE HOME RESIDENCE National Element D_06

Definition Documentation of the type of patient without a home ZIP/Postal code.

Field Values

1-Homeless 3-Migrant Worker

2-Undocumented Citizen


Only completed when ZIP/Postal code is “Not Applicable.”

Homeless is defined as a person who lacks housing. The definition also includes a person living in transitional housing or a supervised public or private facility providing temporary living quarters.

Undocumented Citizen is defined as a national of another country who has entered or stayed in another country without permission.

Migrant Worker is defined as a person who temporarily leaves his/her principal place of residence within a country in order to accept seasonal employment in the same or different country.



1 Face Sheet 2 History and Physical 3 EMS report form





Data format: [Character,1] single entry Pick-list: Yes (non-modifiable) Min. Value: 0 Max. Value: 9 Accepts Null: Yes


2017 40

DEMOGRAPHIC INFORMATION SCC County Element D_24 State Element NA ADMITTING SERVICE National Element NA

Definition Numeric character code from pick list for the in-house service on which the patient is admitted.

Field Values

21 Anesthesiology

13 Burn

29 Cardiology

04 Cardiothoracic

32 Critical Care Medicine

26 DDS

05 ENT/OHNS

18 Emergency Medicine

34 GI

06 General Surgery

28 Infectious Disease

22 Internal Medicine

31 Interventional Radiology

27 Neurology

03 Neurosurgery

15 Non-Surgical Service

07 Obstetrics/Gynecology

08 Ophthalmology

20 Oral or Maxillofacial

02 Orthopedics

30 Pain

23 Pathology

10 Pediatric Intensivist

09 Pediatric Surgery

17 Pediatrics

11 Plastic Surgery

24 Psychiatry

25 Radiology

14 Rehab

33 Renal

19 Replant Service

01 Trauma

16 Urology

12 Vascular/Reimplantation


Pick list can only be modified by consensus with Trauma Executive Committee.


1. Trauma flow sheet 2. Medical Record





Data format: [Character, 2] single entry Pick-list: Yes (non-modifiable) Min. Value: 0 Max. Value: 99 Accepts Null: No


2017 41

DEMOGRAPHIC INFORMATION SCC County Element D_25 State Element NA ADMITTING PHYSICIAN National Element NA

Definition The physician who admits the patient to the hospital.

Field Values


Select from the pick list (customizable)

Autofill



1. Trauma flow sheet 2. Medical Record





Data format: [Character, 3] single entry Pick-list: Yes (modifiable) Min. Value: 0 Max. Value: 9 Accepts Null: No


2017 42

DEMOGRAPHIC INFORMATION SCC County Element D_26 State Element NA ABSTRACTOR National Element NA

Definition The person who abstracts the data to input into the registry.

Field Values


Additional information

The two (2) of three (3) character initials of the person who input the data into this record.


1. Trauma registrar





Data format: [Character, 3] single entry Pick-list: No Min. Value: NA Max. Value: NA Accepts Null: No


2017 43

DEMOGRAPHIC INFORMATION SCC County Element D_27 State Element NA ABSTRACT DATE National Element NA

Definition The date the abstractor performed and completed the abstraction of chart.

Field Values




1. Trauma registrar





Data format: [Numeric date, mm/dd/yyyy] single entry Pick-list: No Min. Value: 01/01/2008 Max. Value: current date Accepts Null: No


2017 44

DEMOGRAPHIC INFORMATION SCC County Element D_28 State Element NA DATA ENTRY DATE National Element NA

Definition Auto-populated date that the registry was opened.

Field Values



Auto-populated.


Auto-populated by the registry





Data format: [Numeric date, mm/dd/yyyy] single entry Pick-list: No Min. Value: 01/01/2008 Max. Value: current date Accepts Null: No


2017 45

PREHOSPITAL INFORMATION


2017 46

PREHOSPITAL INFORMATION SCC County Element P_01 State Element NA NAME National Element NA

Definition Patient name auto-populated by the registry.

Field Values



Auto-populated.







Data format: [Text] single entry Pick-list: No Min. Value: 0 Max. Value: 9 Accepts Null: No


2017 47

PREHOSPITAL INFORMATION SCC County Element P_02 State Element ED_01 HOSPITAL ARRIVAL DATE National Element ED_01

Definition The date the patient arrived to the hospital.

Field Values



Auto-populated from demographics page.







Data format: [Auto-populated, mm/dd/yyyy] single entry Pick-list: No Min. Value: 01/01/2008 Max. Value: current date Accepts Null: No


2017 48

PREHOSPITAL INFORMATION SCC County Element P_03 State Element NA TRAUMA REGISTRY NUMBER National Element NA

Definition This number is assigned by each individual facility, and is auto-populated when record opened.

Field Values



Institution number - Admit month - Registry assigned patient # - Year Example: 20-04-001-07 = VMC – “April” = Admit Month - 001 = Registry assigned patient # - Year is “2007”

Auto-populated.







Data format: [Character,12] single entry Pick-list: No Min. Value: N/A Max. Value: N/A Accepts Null: No


2017 49

PREHOSPITAL INFORMATION SCC County Element P_04 State Element P_07 TRANSPORT MODE National Element P_07

Definition The mode of transport delivering the patient to your hospital.

Field Values

1 Ground Ambulance 5 Police 2 Helicopter Ambulance 6 Other 3 Fixed Wing Ambulance 7 Fire Department 4 Private/Public Vehicle/Walk in



Prehospital Care Record (PCR) for ambulance patients

Nursing/triage flow sheet





0103 4 Transport Mode should not be 4 (Private/Public Vehicle/Walk-in) when EMS response times are not: (1) blank, (2) Not Applicable, or (3) Not Known/Not Recorded


Data format: [Numeric character, 1] single entry Pick-list: Yes Min. Value: 0 Max. Value: 7 Accepts Null: Yes


2017 50

PREHOSPITAL INFORMATION SCC County Element P_05 State Element P_08 OTHER TRANSPORT MODE National Element P_08

Definition All other modes of transport used during patient care event (prior to arrival at your hospital), except the mode delivering the patient to the hospital.

Field Values

1 Ground Ambulance 5 Police 2 Helicopter Ambulance 6 Other 3 Fixed Wing Ambulance 7 Fire Department 4 Private/Public Vehicle/Walk in


Include in “Other” unspecified modes of transport.

The null value “Not Applicable” is used to indicate that a patient had a single mode of transport and therefore this field does not apply to the patient.

Check all that apply with a maximum of 5.


Prehospital Care Record (PCR)





Data format: [Numeric character, 1] single entry Pick-list: Yes Min. Value: 0 Max. Value: 7 Accepts Null: Yes


2017 51

PREHOSPITAL INFORMATION SCC County Element P_06 State Element NA TYPE OF TRANSPORT National Element NA

Definition EMS type of transport.

Field Values

1ST First Responder on scene who did not transport the patient to trauma center. TPT EMS Transport – use for transport from SCENE to HOSPITAL #1 IFT Interfacility Transport – use for transport from first hospital to Trauma Center or Trauma Center to Trauma Center



Prehospital Care Record (PCR)





Data format: [Character] single entry Pick-list: Yes Min. Value: N/A Max. Value: N/A Accepts Null: Yes


2017 52

PREHOSPITAL INFORMATION SCC County Element P_07 State Element NA AGENCY National Element NA

Definition The code for the Prehospital Provider Agency, who transported the patient to the hospital.

Field Values

AMR American Medical Response

BSH Bayshore Ambulance

CAL California Shock Trauma Rescue

CNT Santa Clara County Fire

CHP California Highway Patrol

CRZ Santa Cruz County Fire

LIF Stanford Lifeflight

LPC LPCH Pedi Team

MGR Morgan Hill Fire

MLP Milpitas Fire

MTV Mountain View Fire

PAF Palo Alto Fire

PMP Paramedic Plus

PRO Pro Transport Ambulance

RCH REACH Air Medical Services

RMA Rural Metro of Northern California

SJS San Jose Fire

SNC Santa Clara City Fire

SVA Silicon Valley Ambulance Services

VER Verihealth

WMA Westmed

XSC Santa Clara County EMS

Other



Prehospital Patient Record (PCR)





Data format: [Alpha characters [3] single entry Pick-list: Yes Min. Value: 0 Max. Value: 9 Accepts Null: No


2017 53

PREHOSPITAL INFORMATION SCC County Element P_08 State Element NA PCR Y/N National Element NA

Definition Input by the registrar to indicate the presence or absence of a PCR.

Field Values

Indicate Y if the PCR is on the Patient Record at the hospital

Indicate N if the PCR is missing from the hospital patient record



Patient Medical Record





Data format: [Alpha characters [1] single entry Pick-list: Yes Min. Value: 0 Max. Value: 9 Accepts Null: Yes


2017 54

PREHOSPITAL INFORMATION SCC County Element P_09 State Element NA PCR # National Element NA

Definition The number generated at County Communications related to the incident for which a Prehospital contact occurred.

Field Values

For Santa Clara County Ambulance (Rural Metro), use identifier MXXXXXXXX.

For all other ambulances, use that provider’s specific identifier.



EMS Patient Care Record

County Communications Computer Aided Dispatch (CAD)





Data format: [Alpha/Numeric] single entry Pick-list: No Min. Value: N/A Max. Value: N/A Accepts Null: Yes


2017 55

PREHOSPITAL INFORMATION SCC County Element P_10 State Element P_01 EMS DISPATCH DATE National Element P_01

Definition The date the unit transporting to your hospital was notified by dispatch.

Field Values



Used to auto-generate an additional calculated field: Total EMS Time (elapsed time from EMS dispatch to hospital arrival).

For inter-facility transfer patients, this is the date on which the unit transporting the patient to your facility from the transferring facility was notified by dispatch or assigned to this transport.

For patients transported from the scene of injury to your hospital, this is the date on which the unit transporting the patient to your facility from the scene was dispatched.

The null value “Not Applicable” is used for patients who were not transported by EMS.


EMS PCR

ED Records





0117 3 EMS Dispatch Date is earlier than Date of Birth

0118 4 EMS Dispatch Date is later than EMS Unit Arrival on Scene Date

0119 4 EMS Dispatch Date is later than EMS Unit Scene Departure Date

0120 3 EMS Dispatch Date is later than ED/Hospital Arrival Date

0121 4 EMS Dispatch Date is later than ED Discharge Date

0122 3 EMS Dispatch Date is later than Hospital Discharge Date


Data format: [DATE] single entry Pick-list: No Min. Value: 01/01/1979 Max. Value: Current Date Accepts Null: Yes


2017 56

PREHOSPITAL INFORMATION SCC County Element P_11 State Element P_02 EMS DISPATCH TIME National Element P_02

Definition The time the unit transporting to your hospital was notified by dispatch.

Field Values



Used to auto-generate an additional calculated field: Total EMS Time (elapsed time from EMS dispatch to hospital arrival).

For inter-facility transfer patients, this is the time at which the unit transporting the patient to your facility from the transferring facility was notified by dispatch or assigned to this transport.

For patients transported from the scene of injury to your hospital, this is the time at which the unit transporting the patient to your facility from the scene was dispatched.



EMS PCR

ED Records



0124 1 Time is not valid

0125 1 Time out of range

0126 4 EMS Dispatch Time is later than EMS Unit Arrival on Scene Time

0127 4 EMS Dispatch Time is later than EMS Unit Scene Departure Time

0128 4 EMS Dispatch Time is later than ED/Hospital Arrival Time

0129 4 EMS Dispatch Time is later than ED Discharge Time

0130 4 EMS Dispatch Time is later than Hospital Discharge Time


Data format: [TIME] single entry Pick-list: No Min. Value: 0 Max. Value: 2359 Accepts Null: Yes


2017 57

PREHOSPITAL INFORMATION SCC County Element P_12 State Element P_03 EMS UNIT ARRIVAL DATE AT SCENE OR TRANSFERRING FACILITY National Element P_03

Definition The date the unit transporting to your hospital arrived on the scene/transferring facility.

Field Values



Auto-generated from EMS Dispatch Date. (SCC)

Used to auto-generate an additional calculated field: Total EMS Response Time (elapsed time from EMS dispatch to scene arrival) and Total EMS Scene Time (elapsed time from EMS scene arrival to scene departure.

For inter-facility transfer patients, this is the date on which the unit transporting the patient to your facility from the transferring facility arrived at the transferring facility (arrival is defined at date/time when the vehicle stopped moving).

For patients transported from the scene of injury to your hospital, this is the date on which the unit transporting the patient to your facility from the scene arrived at the scene (arrival is defined at date/time when the vehicle stopped moving).



EMS PCR





0134 3 EMS Unit Arrival on Scene Date is earlier than Date of Birth

0135 4 EMS Unit Arrival on Scene Date is earlier than EMS Dispatch Date

0136 4 EMS Unit Arrival on Scene Date is later than EMS Unit Scene Departure Date

0137 3 EMS Unit Arrival on Scene Date is later than ED/Hospital Arrival Date

0138 4 EMS Unit Arrival on Scene Date is later than ED Discharge Date

0139 3 EMS Unit Arrival on Scene Date is later than Hospital Discharge Date

0140 3 EMS Unit Arrival on Scene Date minus EMS Dispatch Date is greater than 7 days




2017 58

PREHOSPITAL INFORMATION SCC County Element P_13 State Element P_04 EMS UNIT ARRIVAL TIME AT SCENE OR TRANSFERRING FACILITY National Element P_04

Definition The time the unit transporting to your hospital arrived on the scene/transferring facility.

Field Values



Used to auto-generate an additional calculated field: Total EMS Response Time (elapsed time from EMS dispatch to scene arrival) and Total EMS Scene Time (elapsed time from EMS scene arrival to scene departure.

For inter-facility transfer patients, this is the time at which the unit transporting the patient to your facility from the transferring facility arrived at the transferring facility (arrival is defined at date/time when the vehicle stopped moving).

For patients transported from the scene of injury to your hospital, this is the time at which the unit transporting the patient to your facility from the scene arrived at the scene (arrival is defined at date/time when the vehicle stopped moving).



EMS PCR





0144 4 EMS Unit Arrival on Scene Time is earlier than EMS Dispatch Time

0145 4 EMS Unit Arrival on Scene Time is later than EMS Unit Scene Departure Time

0146 4 EMS Unit Arrival on Scene Time is later than ED/Hospital Arrival Time

0147 4 EMS Unit Arrival on Scene Time is later than ED Discharge Time

0148 4 EMS Unit Arrival on Scene Time is later than Hospital Discharge Time




2017 59

PREHOSPITAL INFORMATION SCC County Element P_14 State Element NA EMS UNIT ARRIVAL TIME AT PATIENT National Element NA

Definition The time the unit transporting to your hospital arrived at patient side.

Field Values




EMS PCR





0152 4 EMS Unit Arrival Time at Patient is earlier than EMS Dispatch Time

0153 4 EMS Unit Arrival Time at Patient is earlier than EMS Unit Arrival on Scene Time

0154 4 EMS Unit Arrival Time at Patient is later than EMS Unit Scene Departure Time

0155 4 EMS Unit Arrival Time at Patient is later than ED/Hospital Arrival Time

0156 4 EMS Unit Arrival Time at Patient is later than ED Discharge Time

0157 4 EMS Unit Arrival Time at Patient is later than Hospital Discharge Time




2017 60

PREHOSPITAL INFORMATION SCC County Element P_15 State Element P_05 EMS UNIT DEPARTURE DATE FROM SCENE OR TRANSFERRING FACILITY National Element P_05

Definition The date the unit transporting to your hospital left the scene or transferring facility.

Field Values



Auto-generated from EMS Dispatch Date. (SCC)

Used to auto-generate an additional calculated field: Total EMS Scene Time (elapsed time from EMS scene arrival to scene departure).

For inter-facility transfer patients, this is the date on which the unit transporting the patient to your facility from the transferring facility arrived at the transferring facility (arrival is defined at date/time when the vehicle stopped moving).

For patients transported from the scene of injury to your hospital, this is the date on which the unit transporting the patient to your facility from the scene arrived at the scene (arrival is defined at date/time when the vehicle stopped moving).



EMS PCR





0161 3 EMS Unit Scene Departure Date is earlier than Date of Birth

0162 4 EMS Unit Scene Departure Date is earlier than EMS Dispatch Date

0163 4 EMS Unit Scene Departure Date is earlier than EMS Unit Arrival on Scene Date

0164 3 EMS Unit Scene Departure Date is later than ED/Hospital Arrival Date

0165 4 EMS Unit Scene Departure Date is later than ED Discharge Date

0166 3 EMS Unit Scene Departure Date is later than Hospital Discharge Date

0167 3 EMS Unit Scene Departure Date minus EMS Unit Arrival on Scene Date is greater than 7 days




2017 61

PREHOSPITAL INFORMATION SCC County Element P_16 State Element P_06 EMS UNIT DEPARTURE TIME FROM SCENE OR TRANSFERRING FACILITY National Element P_06

Definition The time the unit transporting to your hospital left the scene or transferring facility.

Field Values



Used to auto-generate an additional calculated field: Total EMS Scene Time (elapsed time from EMS scene arrival to scene departure).

For inter-facility transfer patients, this is the time at which the unit transporting the patient to your facility from the transferring facility arrived at the transferring facility (arrival is defined at date/time when the vehicle stopped moving).

For patients transported from the scene of injury to your hospital, this is the time at which the unit transporting the patient to your facility from the scene arrived at the scene (arrival is defined at date/time when the vehicle stopped moving).



EMS PCR





0171 4 EMS Unit Scene Departure Time is earlier than EMS Dispatch Time

0172 4 EMS Unit Scene Departure Time is earlier than EMS Unit Arrival on Scene Time

0173 4 EMS Unit Scene Departure Time is later than ED/Hospital Arrival Time

0174 4 EMS Unit Scene Departure Time is later than ED Discharge Time

0175 4 EMS Unit Scene Departure Time is later than Hospital Discharge Time




2017 62

PREHOSPITAL INFORMATION SCC County Element P_17 State Element NA EMS UNIT DESTINATION TIME National Element NA

Definition The time the unit transporting to your hospital arrives at the Trauma Center.

Field Values




EMS PCR





0179 4 EMS Unit Destination Time is earlier than EMS Dispatch Time

0180 4 EMS Unit Destination Time is earlier than EMS Unit Arrival on Scene Time

0181 4 EMS Unit Destination Time is later than ED/Hospital Arrival Time

0182 4 EMS Unit Destination Time is later than ED Discharge Time

0183 4 EMS Unit Destination Time is later than Hospital Discharge Time




2017 63

PREHOSPITAL INFORMATION SCC County Element P_18 State Element NA EMS UNIT RESPONSE TIME National Element NA

Definition Auto-calculated: the difference between the time of dispatch and scene arrival.

Field Values



Collected as MM.


EMS PCR





Data format: [TIME] single entry Pick-list: No Min. Value: 0 Max. Value: NA Accepts Null: Yes


2017 64

PREHOSPITAL INFORMATION SCC County Element P_19 State Element NA EMS UNIT SCENE TIME National Element NA

Definition Auto-calculated: the difference between the AT SCENE TIME and time that ambulance DEPARTS SCENE to go to your hospital.

Field Values



Collected as MM.


EMS PCR







2017 65

PREHOSPITAL INFORMATION SCC County Element P_20 State Element NA EMS UNIT TRANSPORT TIME National Element NA Definition Auto-calculated: the difference between the DEPARTURE TIME and time that ambulance arrives at DESTINATION - at your hospital.

Field Values



Collected as MM.


EMS PCR

Hospital arrival time







2017 66

PREHOSPITAL INFORMATION SCC County Element P_21 State Element P_18 TRAUMA CENTER CRITERIA National Element P_18

Definition Physiologic and anatomic EMS trauma triage criteria for transport to a trauma center as defined by the Centers for Disease Control and Prevention and the American College of Surgeons-Committee on Trauma. This information must be found on the scene of injury EMS Run Report.

Field Values

100 Physiologic criteria (Adult)

110 GCS <14*

130 RR <10 or >29 breaths per minute or need for ventilatory support

120 BP <90 mmHg

200 Physiologic criteria (Pediatric)

210 GSC <14*

220 SBP <60 (age <6 Y)

230 SBP <90 (age >6 Y*)

240 RR <10 or >29* breaths per minute or need for ventilatory support

250 RR <20 under 1 Y

300 Anatomic criteria

310 All penetrating injuries to head, neck, torso, and extremities proximal to elbow or knee*

320 Two or more proximal long-bone fractures*

330 Traumatic paralysis or paresthesias*

340 Chest wall instability or deformity (e.g., flail chest)*

350 Amputations proximal to the wrist or ankle*

360 Suspected pelvic fractures*

370 CNS changes witnessed by prehospital personnel that include the following: 1. Post traumatic seizure. 2. Transitory or prolonged loss of consciousness (LOC). 3. Hemiparesis.

380 Crushed, degloved, mangled or pulseless extremity*

390 Open or depressed skull fracture*

400 Mechanism of Injury criteria

411 HRAC estimated impact speed >40 mph

412 HRAC major auto deformity* intrusion >12 inches occupant site or >18 inches any other site

413 HRAC significant structural vehicle damage caused by occupant.

414 HRAC ejection from vehicle (partial or complete)

415 HRAC death of passenger in vehicle

416 HRAC prolonged extrication

417 HRAC rollover with unrestrained occupant

421 Falls Adult >20 feet* (one story is equal to 10 ft.)

422 Falls Peds >10 feet or 2-3 times the height of the child*


2017 67

440 Motorcycle crash >20 mph

435 Auto v. pedestrian/bicyclist thrown, run over, or > 20 MPH impact

445 Crash Vehicle Telemetry Data (AACN) consistent with high risk injury

500 Special Considerations

510 Patients greater than 55 years old

520 Pediatric considerations

530 Comorbid factors

540 Alcohol/Drug influence and/or foreign language

550 Patients on anticoagulants and bleeding disorders

560 Patient with end stage renal disease requiring dialysis

570 Time-sensitive extremity injury

580 EMS Provider judgment

590 Burns

515 For adults > 65; SBP < 110

910 Pregnancy > 20 weeks

595 Burns with trauma

Other Considerations

600 Patient refused transport

700 Patient downgraded after base contact

710 Directed by base hospital

800 Patient transported to non-trauma center, w/o base contact

900 ED Trauma Team Activation


Required by NTDB 2016 (SCC).

The null value “Not Applicable” should be used to indicate that the patient did not arrive by EMS.

The null value “Not Applicable” should be used if EMS Run Report indicates patient did not meet any Trauma Center Criteria.

The null value “Not Known/Not Recorded” should be used if this information is not indicated, as an identical response choice, on the EMS Run Report or if the EMS Run Report is not available.

Check all that apply.


EMS PCR




Data format: [numeric (3)] Pick-list: Yes

Min. Value: 100 Max. Value: 900 Accepts Null: No


2017 68

PREHOSPITAL INFORMATION SCC County Element P_22 State Element P_20 PREHOSPITAL CARDIAC ARREST National Element P_20

Definition Indication of whether patient experienced cardiac arrest prior to ED/Hospital arrival.

Field Values

1. Yes

2. No


A patient who experienced a sudden cessation of cardiac activity. The patient was unresponsive with no normal breathing and no signs of circulation.

The event must have occurred outside of the reporting hospital, prior to admission at the center in which the registry is maintained. Pre-hospital cardiac arrest could occur at a transferring institution.

Any component of basic and/or advanced cardiac life support must have been initiated by a health care provider.


EMS PCR






Data format: [numeric (1)] single entry Pick-list: Yes Min. Value: 1 Max. Value: 2 Accepts Null: No


2017 69

PREHOSPITAL INFORMATION SCC County Element P_23 State Element NA PREHOSPITAL PROCEDURES National Element NA Definition The coded treatments done prior to arrival at the receiving facility.

Field Values

03 CPR 06 Cricothyrotomy 99 Other 17 Pelvic Binder 01 Endotracheal intubation 07 Pleural Decompression 05 Full spinal immobilization 24 Alternate Airway device (LMA, King/Combi) Additional Information

Data Source Hierarchy EMS PCR Associated Edit Checks



Data format: [numeric (2)] single entry Pick-list: Yes Min. Value: 01 Max. Value: 99 Accepts Null: No


2017 70

PREHOSPITAL INFORMATION SCC County Element P_24 State Element NA TRANSPORT TYPE National Element NA

Definition

The type of provider which responds to the incident.

Field Values

1ST First Responder on scene who did not transport the patient to trauma center. TPT EMS Transport – use for transport from SCENE to HOSPITAL #1 IFT Interfacility Transport – use for transport from first hospital to Trauma Center or

Trauma Center to Trauma Center

Additional Information Data Source Hierarchy EMS PCR Associated Edit Checks




Data format: [alpha/numeric (3)] single entry Pick-list: Yes Min. Value: NA Max. Value: NA Accepts Null: No


2017 71

PREHOSPITAL INFORMATION SCC County Element P_25 State Element NA VITAL SIGNS DATE National Element NA

Definition

The date of the patient encounter.

Field Values




EMS PCR





Data format: [DATE] single entry Pick-list: No Min. Value: 01/01/1979 Max. Value: current date Accepts Null: No


2017 72

PREHOSPITAL INFORMATION SCC County Element P_26 State Element NA VITAL SIGNS TIME National Element NA

Definition

The time of the patient encounter.

Field Values




EMS PCR





Data format: [TIME] single entry Pick-list: Yes Min. Value: 00 Max. Value: 2359 Accepts Null: No


2017 73

PREHOSPITAL INFORMATION SCC County Element P_27 State Element P_10 INITIAL FIELD PULSE RATE National Element P_10

Definition

First recorded pulse measured at the scene of injury (palpated or auscultated), expressed as a

number per minute.

Field Values



The null value “Not Known/Not Recorded” is used if the patient is transferred to your

facility with no EMS Run Report from the scene of injury.

Measurement recorded must be without the assistance of CPR or any type of

mechanical chest compression device. For those patients who are receiving CPR or any

type of mechanical chest compressions, report the value obtained while compressions

are paused.

The null value “Not Applicable” is used for patients who arrive by 4. Private/Public

Vehicle/Walk-in.


EMS PCR

First reported vital signs regardless of provider agency. Can be a combination of first

responder and transport providers. (SCC)

If available on inter-facility transports, pulse rate from the scene should be reported.

(SCC)





0204 3 Pulse rate exceeds the max of 299

Data format: [Numeric] single entry Pick-list: No Min. Value: 01 Max. Value: 299 Accepts Null: No


2017 74

PREHOSPITAL INFORMATION SCC County Element P_28 State Element P_11 INITIAL FIELD RESPIRATORY RATE National Element P_11

Definition

First recorded respiratory rate measured at the scene of the injury (expressed as a number per

minute).

Field Values







If available on inter-facility transports, respiratory rate from the scene should be

reported. (SCC)


Vehicle/Walk-in.


EMS PCR



0205 1 Invalid value. RR cannot be > 99 for age in years >=6 OR RR cannot be > 120 for age in years < 6. If age and age units are not valued, RR cannot be > 120.


0207 3 Invalid, out of range. RR cannot be > 99 and <=120 for age in years < 6. If age and age units are not valued, RR cannot be > 99.



2017 75

PREHOSPITAL INFORMATION SCC County Element P_29 State Element NA INITIAL FIELD RESPIRATORY RATE QUALIFIER National Element NA

Definition

This element defines whether or not the respirations are self-sustaining or require assistance.

Field Values

A Assisted U Unassisted






If available on inter-facility transports, respiratory rate qualifier from the scene should be

reported. (SCC)


EMS PCR





Data format: [Alpha] single entry Pick-list: Yes Min. Value: NA Max. Value: NA Accepts Null: No


2017 76

PREHOSPITAL INFORMATION SCC County Element P_30 State Element P_12 INITIAL FIELD OXYGEN SATURATION National Element P_12

Definition

First recorded oxygen saturation measured at the scene of injury (expressed as a percentage).

Field Values





Value should be based upon assessment before administration of supplemental oxygen.



If available on inter-facility transports, oxygen saturation from the scene should be

reported. (SCC)


Vehicle/Walk-in.


EMS PCR



0210 1 Pulse oximetry is outside the valid range of 0 – 100


Data format: [Numeric percentage] single entry Pick-list: No Min. Value: 0 Max. Value: 100 Accepts Null: No


2017 77

PREHOSPITAL INFORMATION SCC County Element P_31 State Element P_09 INITIAL FIELD SYSTOLIC BLOOD PRESSURE National Element P_09

Definition

First recorded systolic blood pressure measured at the scene of injury.

Field Values







If available on inter-facility transports, systolic blood pressure from the scene should be

reported. (SCC)

Measurement recorded must be without the assistance of CPR or any type of

mechanical chest compression device. For those patients who are receiving CPR or any

type of mechanical chest compressions, report the value obtained while compressions

are paused.


Vehicle/Walk-in.


EMS PCR





0214 3 SBP exceeds the max of 300



2017 78

PREHOSPITAL INFORMATION SCC County Element P_32 State Element NA INITIAL FIELD DIASTOLIC BLOOD PRESSURE National Element NA

Definition

First recorded diastolic blood pressure measured at the scene of injury.

Field Values







If available on inter-facility transports, diastolic blood pressure from the scene should be

reported. (SCC)


EMS PCR





0217 3 DBP exceeds the max of 300



2017 79

PREHOSPITAL INFORMATION SCC County Element P_33 State Element P_13 INITIAL FIELD GCS – EYE National Element P_13

Definition

First recorded Glasgow Coma Score (Eye) measured at the scene of injury.

Field Values

Score Qualifier

4 Opens eyes spontaneously

3 Opens eyes in response to verbal stimulation

2 Opens eyes in response to painful stimulation

1 No eye movement when assessed


Used to calculate Overall GCS – EMS Score.



If available on inter-facility transports, GCS - Eye from the scene should be reported.

(SCC)

If a patient does not have a numeric GCS score recorded, but written documentation

closely (or directly) relates to verbiage describing a specific level of functioning within the

GCS scale, the appropriate numeric score may be listed. E.g. the chart indicates:

“patient pupils are PERRL,” an Eye GCS of 4 may be recorded, IF there is no other

contradicting documentation.


Vehicle/Walk-in.


EMS PCR





Data format: [Numeric] single entry Pick-list: Yes, non-modifiable Min. Value: 1 Max. Value: 4 Accepts Null: No


2017 80

PREHOSPITAL INFORMATION SCC County Element P_34 State Element P_15 INITIAL FIELD GCS - MOTOR National Element P_15

Definition

First recorded Glasgow Coma Score (Motor) measured at the scene of injury.

Field Values

Pediatric (≤ 2 years):

1 No motor response

2 Extension to pain

3 Flexion to pain

4 Withdrawal from pain

5 Localizing pain

6 Appropriate response to stimulation

Adult:

1 No motor response

2 Extension to pain

3 Flexion to pain


5 Localizing pain

6 Obeys commands





If available on inter-facility transports, GCS - Motor from the scene should be reported.

(SCC)




“patient withdraws from a painful stimulus,” a Motor GCS of 4 may be recorded, IF there

is no other contradicting documentation.


Vehicle/Walk-in.


EMS PCR







2017 81

PREHOSPITAL INFORMATION SCC County Element P_35 State Element P_14 INITIAL FIELD GCS - VERBAL National Element P_14

Definition

First recorded Glasgow Coma Score (Verbal) measured at the scene of injury.

Field Values


5 Smiles, oriented to sounds, follows objects, interacts

4 Cries but is consolable, inappropriate interactions

3 Inconsistently consolable, moaning

2 Inconsolable, agitated

1 No vocal response

Adult:

5 Oriented

4 Confused

3 Inappropriate words

2 Incomprehensible sounds

1 No verbal response





If available on inter-facility transports, GCS - Verbal from the scene should be reported.

(SCC)

If patient is intubated then the GCS Verbal score is equal to 1.




“patient is oriented to person place and time,” a Verbal GCS of 5 may be recorded, IF

there is no other contradicting documentation.


Vehicle/Walk-in.


EMS PCR







2017 82

PREHOSPITAL INFORMATION SCC County Element P_36 State Element P_16 INITIAL FIELD GCS - TOTAL National Element P_16

Definition

First recorded Glasgow Coma Score (total) measured at the scene of injury.

Field Values





If available on inter-facility transports, GCS - Total from the scene should be reported.

(SCC)

If a patient does not have a numeric GCS recorded, but there is documentation related

to their level of consciousness such as “AAOx3,” “awake alert and oriented,” or “patient

with normal mental status,” interpret this as GCS of 15 IF there is no other contradicting

documentation.


Vehicle/Walk-in.


EMS PCR



0224 1 GCS Total is outside the valid range of 3 - 15

0225 4 Initial Field GCS – Total does not equal the sum of Initial Field GCS – Eye, Initial Field GCS – Verbal, and Initial Field GCS - Motor




2017 83

PREHOSPITAL INFORMATION SCC County Element P_37 State Element NA INITIAL FIELD GCS QUALIFIER National Element NA

Definition

This is a description of the barriers to evaluation of the GCS.

Field Values

Qualifier Description

1 Chemically sedated

3 Intubated

L Legitimate values without intubation or sedation

2 Obstruction to patient’s eyes



EMS PCR





Data format: [Alpha/Numeric] single entry Pick-list: Yes Min. Value: NA Max. Value: NA Accepts Null: No


2017 84

PREHOSPITAL INFORMATION SCC County Element P_38 State Element NA INITIAL FIELD REVISED TRAUMA SCORE National Element NA

Definition

The Revised Trauma Score is a physiological scoring system, which has demonstrated

accuracy in predicting death. It is scored from the first set of data obtained on the patient, and

consists of Glasgow Coma Scale, Systolic Blood Pressure and Respiratory Rate.

Field Values

Auto-calculated by Trauma One based on the GCS, SBP and RR



EMS PCR





Data format: [Numeric] single entry Pick-list: No Min. Value: Auto-calculated Max. Value: Auto-calculated Accepts Null: No

http://www.trauma.org/archive/scores/gcs.html


2017 85

INJURY INFORMATION


2017 86

INJURY INFORMATION SCC County Element I_01 State Element I_01 INJURY INCIDENT DATE National Element I_01

Definition

The date the injury occurred.

Field Values



Estimates of date of injury should be based upon report by patient, witness, family, or

health care provider. Other proxy measures (e.g., 911 call times) should not be used.


EMS PCR






0234 4 Injury Incident Date is earlier than Date of Birth

0235 4 Injury Incident Date is later than EMS Dispatch Date

0236 4 Injury Incident Date is later than EMS Unit Arrival on Scene Date

0237 4 Injury Incident Date is later than EMS Unit Scene Departure Date

0238 4 Injury Incident Date is later than ED/Hospital Arrival Date

0239 4 Injury Incident Date is later than ED Discharge Date

0240 4 Injury Incident Date is later than Hospital Discharge Date

Data format: [Numeric] single entry Pick-list: No Min. Value: 01/01/2008 Max. Value: Current date Accepts Null: No


2017 87

INJURY INFORMATION SCC County Element I_02 State Element I_02 INJURY INCIDENT TIME National Element I_02

Definition

The time the injury occurred.

Field Values



Estimates of time of injury should be based upon report by patient, witness, family, or

health care provider. Other proxy measures (e.g., 911 call times) should not be used.


EMS PCR






0244 4 Injury Incident Time is later than EMS Dispatch Time

0245 4 Injury Incident Time is later than EMS Unit Arrival on Scene Time

0246 4 Injury Incident Time is later than EMS Unit Scene Departure Time

0247 4 Injury Incident Time is later than ED/Hospital Arrival Time

0248 4 Injury Incident Time is later than ED Discharge Time

0249 4 Injury Incident Time is later than Hospital Discharge Time




2017 88

INJURY INFORMATION SCC County Element I_04 State Element I_07 ICD-10 PLACE OF OCCURRENCE EXTERNAL CAUSE CODE National Element I_07

Definition

Place of occurrence external cause code used to describe the place/site/location of the injury

event (Y92.X).

Field Values

Relevant ICD-10-CM code value for injury event


Only ICD-10-CM codes will be accepted for ICD-10 Place of Occurrence External Cause

Code.

Refer to Appendix 3: Glossary of Terms for multiple cause coding hierarchy.


1. EMS PCR

2. ED Records

3. Billing sheets



0251 1 Invalid value (ICD-10-CM only)


0253 3 Place of injury code should be Y92.X/Y92.XX/Y92.XXX (where X is A-Z [excluding I,O] or 0-9) (ICD-10 CM only)

0254 1 Invalid value (ICD-10 CA only)

0255 3 Place of Injury code should be U98X (where X is 0-9) (ICD-10 CA only)


Data format: [Numeric] single entry Pick-list: YES Min. Value: 0 Max. Value: 9 Accepts Null: NO


2017 89

INJURY INFORMATION SCC County Element I_05 State Element I_09 INCIDENT LOCATION ZIP/POSTAL CODE National Element I_09

Definition

The ZIP/Postal code of the incident location.

Field Value



Can be stored as a 5 or 9 digit code (XXXXX-XXXX) for US and CA, or can be stored in the postal code format of the applicable country.

If “Not Known/Not Recorded,” complete variables: Incident County, Incident State (US Only), Incident County (US Only) and Incident City (US Only).

May require adherence to HIPAA regulations.

If ZIP/Postal code is known, then must complete Incident Country.


1. EMS report form

2. ED records

3. Billing Sheets, Medical records coding sheets






Data format: Numeric Pick-list: No Min. Value: NA Max. Value: NA Accepts Null: Yes


2017 90

INJURY INFORMATION SCC County Element I_06 State Element I_13 INCIDENT CITY National Element I_13

Definition The city or township where the patient was found or to which the unit responded. Field Values

Picklist contains all cities in the state of California Additional Information

Select city from picklist, or enter non-picklisted city directly.

Only completed when Incident Location ZIP/Postal code is "Not Known/Not Recorded." and country is US.

Used to calculate FIPS code.

If incident location resides outside of formal city boundaries, report nearest city/town.

The null value “Not Applicable” is used if Incident Location ZIP/Postal Code is reported.

If Incident Country is not US, report the null value “Not Applicable”. Data Source Hierarchy 1. EMS Report Form 2. ED Records






Data format: [character, 30] single entry Pick-list: Yes non-modifiable Min. Value: NA Max. Value: NA Accepts Null: Yes


2017 91

INJURY INFORMATION SCC County Element I_07 State Element I_12 INCIDENT COUNTY National Element I_12

Definition The county or parish where the patient was found or to which the unit responded (or best approximation). Field Values

All counties in the State of California Additional Information • Select county from pick list. • Only completed when Incident Location ZIP/Postal code is “Not Known/Not Recorded”, and

country is US. • Used to calculate FIPS code.










2017 92

INJURY INFORMATION SCC County Element I_08 State Element I_11 INCIDENT STATE National Element I_11

Definition The state, territory, or province where the patient was found or to which the unit responded (or best approximation). Field Values

Relevant value for data element (two digit numeric FIPS code) Additional Information • Only completed when Incident Location ZIP/Postal code is “Not Known/Not Recorded”, and

country is US. • Used to calculate FIPS code.










2017 93

INJURY INFORMATION SCC County Element I_09 State Element I_10 INCIDENT COUNTRY National Element I_10

Definition The country where the patient was found or to which the unit responded (or best approximation). Field Values

Two digit code for all the countries listed Additional Information

• Select country from picklist.

If Incident Country is not US, then the null value “Not Applicable” is used for: Incident State, Incident County, and Incident City.


1. EMS Report Form 2. ED Records






0272 2 Field cannot be Not Known/Not Recorded when Home Zip is not: (1) blank, (2) Not Applicable, or (3) Not Known/Not Recorded

Data format: [numeric] single entry Pick-list: Yes non-modifiable Min. Value: NA Max. Value: NA Accepts Null: Yes


2017 94

INJURY INFORMATION SCC County Element I_10 State Element NA INJURY TYPE National Element NA

Definition The type of injury that occurred. Field Values

B Blunt

P Penetrating

U Burns Additional Information • Select from picklist Data Source Hierarchy 1. EMS Report Form 2. ED Records





Data format: [CHARACTER, 30] single entry Pick-list: Yes non-modifiable Min. Value: NA Max. Value: NA Accepts Null: Yes


2017 95

INJURY INFORMATION SCC County Element I_11 State Element NA CAUSE OF INJURY National Element NA

Definition The Santa Clara County two-digit code describing the mechanism of the patient’s injury

Field Values

03 Assault

06 Bicycle

02 Fall

07 GSW

09 Impalement

04 MCC

01 MVC

11 Other Blunt

10 Other Penetrating

05 Pedestrian

08 Stabbing

Additional Information • If the patient has a Mechanism of Injury (MOI) that fits multiple field values, Enclosed Vehicle (EV), Extrication Required (EX), Passenger Space Intrusion (PS), use the primary MOI (EV) followed by the subcategories (EX & PS) Data Source Hierarchy 1. EMS Report Form (preferred) 2. ED Records (if above determined to be inaccurate or incomplete)







2017 96

INJURY INFORMATION SCC County Element I_12 State Element I_03 WORK-RELATED National Element I_03

Definition Indication of whether the injury occurred during paid employment Field Values • Y (Yes) • N (No) Additional Information • If work related, two additional data fields must be completed: Patient's Occupational Industry

and Patient's Occupation Data Source Hierarchy 1. ED Records 2. EMS Report Form





0279 4 Work-Related should be 1 (Yes) when Patient’s Occupation is not: (1) blank, (2) Not Applicable, or (3) Not Known/Not Recorded

0280 4 Work-Related should be 1 (Yes) when Patient’s Occupational Industry is not: (1) blank, (2) Not Applicable, or (3) Not Known/Not Recorded

0281 2 Field cannot be Not Applicable.



2017 97

INJURY INFORMATION SCC County Element I_13 State Element I_04 PATIENT’S OCCUPATIONAL INDUSTRY National Element I_04

Definition The occupational industry associated with the patient’s work environment.

Field Values

Industry Components

05 Agricultural Agriculture, Forestry, Fishing

08 Construction

07 Education and Health Services

01 Finance Finance, Insurance, Real Estate

09 Government

13 Leisure Leisure and Hospitality

02 Manufacturing

10 Natural Resources Natural Resources and Mining

06 Professional Professional and Business Services

03 Retail Retail Trade

04 Transportation and Public Utilities

20 Information Services

12 Wholesale

11 Other Services

Additional Information • If work related, also complete Patient's Occupation.

Based upon US Bureau of Labor Statistics Industry Classification.

The null value “Not Applicable” is used if Work Related is 2. No. Data Source Hierarchy 1. Facesheet 2. History & Physical 3. ED Nurses Notes 4. Triage Form / Trauma Flow Sheet 5. EMS Report Form





Data Format: [character, 15] single entry Pick list: Yes, non-modifiable Min Value: N/A Max Value: N/A Accepts Null Value: Yes


2017 98

INJURY INFORMATION SCC County Element I_14 State Element I_05 PATIENT’S OCCUPATION National Element I_05

Definition The occupation of the patient.

Field Values

Category

02 Architecture and Engineering

16 Arts, Design, Entertainment, Sports and Media

07 Building and Grounds Cleaning and Maintenance

01 Business and Financial Operations

03 Community and Social Services

13 Computer and Mathematical

21 Construction and Extraction

04 Education, Training, and Library

09 Farming, Fishing, and Forestry

18 Food Preparation and Serving

05 Healthcare Practitioners and Technical

17 Healthcare Support

10 Installation, Maintenance and Repair

15 Legal

14 Life, Physical, and Social Science

12 Management

23 Military Specific

20 Office and Administrative Support

19 Personal Care and Service

22 Production

06 Protective Service

08 Sales and Related

11 Transportation and Material Moving

Additional Information • Only completed if injury is work-related – must also complete Patient's Occupational Industry. • Based upon 1999 US Bureau of Labor Statistics Standard Occupational Classification (SOC). Data Source Hierarchy 1. Facesheet 2. History & Physical 3. ED Nurses Notes 4. Triage Form / Trauma Flow Sheet 5. EMS Report Form


2017 99





Data Format: [character, 15] single entry Picklist: Yes, non-modifiable Min Value: N/A Max Value: N/A Accepts Null Value: Yes


2017 100

INJURY INFORMATION SCC County Element I_15 State Element NA FALL HEIGHT (FT) National Element NA

Definition

Documents the height of a fall.

Field Values

Use the height in feet and/or inches from the level of the fall. Do not include patient’s

height in the calculation.




ED Patient Care Record





Data Format: [numeric, 3] single entry Picklist: No Min Value: 0 Max Value: 20 Accepts Null Value: Yes


2017 101

INJURY INFORMATION SCC County Element I_17 State Element I_06 ICD-10 PRIMARY EXTERNAL CAUSE CODE National Element I_06

Definition External cause code used to describe the mechanism (or external factor) that caused the injury event. Field Values • Relevant ICD-10-CM code value for injury event Additional Information • The primary external cause code should describe the main reason a patient is admitted to the

hospital. • ICD-10-CM Codes will be accepted for this data element. Activity codes should not be

reported in this field.

Data Source Hierarchy 1. EMS Report Form 2. ED Records 3. Billing Sheet / Medical Records Coding Summary Sheet Associated Edit Checks


0288 1 E-Code is not a valid ICD-10-CM code (ICD-10 CM only)


0290 2 Should not be Y92.X/Y92.XX/Y92.XXX (where X is A-Z or 0-9) (ICD-10 CM only)

0291 3 ICD-10 External Cause Code should not be Y93.X/Y93.XX (where X is A-Z or 0-9) (ICD-10 CM only)

0292 1 E-Code is not a valid ICD-10-CA code (ICD-10 CA only)


Data Format: [character, 6] single entry Picklist: Yes Min Value: NA Max Value: NA Accepts Null Value: Yes


2017 102

INJURY INFORMATION SCC County Element I_19 State Element I_08 ICD-10 ADDITIONAL EXTERNAL CAUSE CODE National Element I_08

Definition Additional External Cause Code used in conjunction with the Primary External Cause Code if multiple external cause codes are required to describe the injury event. Field Values • Relevant ICD-10-CM code value for injury event Additional Information • Only ICD-10-CM codes will be accepted for ICD-10 Additional External Cause Code. • Activity codes should not be reported in this field. • Refer to Appendix 3: Glossary of Terms for multiple cause coding hierarchy. • The null value “Not Applicable” is used if no additional external cause codes are used. Data Source Hierarchy 1. EMS Report Form 2. ED Records 3. Billing Sheet / Medical Records Coding Summary Sheet Associated Edit Checks


0294 1 E-Code is not a valid ICD-10-CM code (ICD-10 CM only)

0295 4 Additional External Cause Code ICD-10 should not be equal to Primary External Cause Code ICD-10


0297 1 E-Code is not a valid ICD-10-CA code (ICD-10 CA only)

Data Format: [character, 6] single entry Picklist: Yes Min Value: NA Max Value: NA Accepts Null Value: Yes


2017 103

INJURY INFORMATION SCC County Element I_20 State Element NA PATIENT LOCATION IN VEHICLE National Element NA

Definition

For documentation in a Motor Vehicle incident, of location of patient in vehicle.

Field Values

Numeric Values Location

11 Child Rest-Back-NFS

09 Child Rest-Center Rear

10 Child Rest –Front Pass

07 Child Rest – Left Rear

13 Child Rest – NFS

08 Child Rest – Right Rear

01 Driver

14 Outside of Vehicle

05 Pass – Center Rear Seat

02 Pass – Front Seat

03 Pass – Left Rear Seat

12 Pass – NFS

06 Pass – Rear Seat NFS

04 Pass – Rear Right Seat



EMS Patient Record

ED Patient Record





Data Format: [character, 2] single entry Pick list: Yes Min Value: 0 Max Value: 15 Accepts Null Value: Yes


2017 104

INJURY INFORMATION SCC County Element I_21 State Element I_14 PROTECTIVE DEVICES National Element I_14

Definition

Protective devices (safety equipment) in use or worn by the patient at the time of the injury.

Field Values

Numeric Values Selection

08 Airbag Present

06 Child Restraint (booster seat or child car seat)

05 Eye Protection

07 7B 7G 7E 7F

Helmet

Bicycle

Motorcycle

Sports

NFS

02 Lap Belt

01 None

11 Other

03 Personal Floatation Device

09 Protective Clothing (e.g., padded leather pants)

04 Protective Non-Clothing Gear (e.g., shin guard)

10 Shoulder Belt

12 Sports Equipment


Check all that apply

If “Child Restraint” is present, complete variable “Child Specific Restraint.”

If “Airbag” is present, complete variable “Airbag Deployment.”

Evidence of the use of safety equipment may be reported or observed.

Lap Belt should be used to include those patients that are restrained, but not further

specified.

If chart indicates “3-point restraint” choose 2. Lap Belt and 10. Shoulder Belt.



ED Patient Care Record.






2017 105

0302 3 Protective Device should be 6 (Child Restraint), when Child Specific Restraint is not: (1) blank, (2) Not Applicable, or (3) Not Known/Not Recorded

0303 3 Protective Device should be 8 (Airbag Present) when Airbag Deployment is not: (1) blank, (2) Not Applicable, or (3) Not Known/Not Recorded


Data Format: [character, 2] single entry Pick list: Yes non-modifiable Min Value: 0 Max Value: 99 Accepts Null Value: Yes


2017 106

INJURY INFORMATION SCC County Element I_22 State Element NA INCIDENT COMMENTS National Element NA

Definition

Brief description of how the injury occurred.

Field Values

Free text.




ED Patient Care Record




Data Format: [character] free text Pick list: No Min Value: NA Max Value: NA Accepts Null Value: Yes


2017 107

INJURY INFORMATION SCC County Element I_23 State Element I_15 CHILD SPECIFIC RESTRAINT National Element I_15

Definition

Protective child restraint devices used by patient at the time of injury.

Field Values

61 Child Car Seat

62 Infant Car Seat

63 Child Booster Seat


Evidence of the use of child restraint may be reported or observed.

Only completed when Protective Devices include “Child Restraint.”


EMS Patient care record





0308 2 Field cannot be Not Applicable when Protective Device is 6 (Child Restraint)

Data Format: [character, 1] Pick list: Yes Min Value: 1 Max Value: 3 Accepts Null Value: Yes


2017 108

INJURY INFORMATION SCC County Element I_24 State Element I_16 AIRBAG DEPLOYMENT National Element I_16

Definition

Indication of airbag deployment during a motor vehicle crash.

Field Values

1 Airbag Not Deployed

2 Airbag Deployed Front

3 Airbag Deployed Side

4 Airbag Deployed Other (knee, airbelt, curtain, etc.)



Evidence of the use of airbag deployment may be reported or observed.

Only completed when Protective Devices include “Airbag.”

Airbag Deployed Front should be used for patients with documented airbag

deployments, but are not further specified.

The null value “Not Applicable” is used if no “Airbag Present” is reported under

Protective Devices.


EMS Patient care record





0311 2 Field cannot be Not Applicable when Protective Device is 8 (Airbag Present)



2017 109

INJURY INFORMATION SCC County Element I_25 State Element I_17 REPORT OF PHYSICAL ABUSE National Element I_17

Definition

A report of suspected physical abuse was made to law enforcement and/or protective services.

Field Values

1 Yes

2 No


This includes, but is not limited to, a report of child, elder, spouse or intimate partner

physical abuse.









2017 110

INJURY INFORMATION SCC County Element I_26 State Element I_18 INVESTIGATION OF PHYSICAL ABUSE National Element I_18

Definition

An investigation by law enforcement and/or protective services was initiated because of the

suspected physical abuse.

Field Values

1 Yes

2 No


This includes, but is not limited to, a report of child, elder, spouse or intimate partner

physical abuse.

Only complete when Report of Physical Abuse is 1. Yes.

The null value “Not Applicable” should be used for patients where Report of Physical

Abuse is 2. No.






0317 3 Field should not be Not Applicable when Report of Physical Abuse = 1 (Yes)



2017 111

INJURY INFORMATION SCC County Element I_27 State Element I_19 CAREGIVER AT DISCHARGE National Element I_19

Definition

The patient was discharged to a caregiver different than the caregiver at admission due to

suspected physical abuse.

Field Values

1 Yes

2 No


Only complete when Report of Physical Abuse is 1. Yes.

Only complete for minors as determined by state/local definition, excluding emancipated

minors.

The null value “Not Applicable” should be used for patients where Report of Physical

Abuse is 2. No or where older than the state/local age definition of a minor.

The null value “Not Applicable” should be used if the patient expires prior to discharge.






Data Format: [character, 1] Pick list: Yes

Min Value: 1 Max Value: 2 Accepts Null Value: Yes


2017 112

REFER IN INFORMATION


2017 113

REFER IN INFORMATION SCC County Element R_01 State Element NA DATE OF ARRIVAL National Element NA

Definition

The date the trauma victim arrived at the referring facility.

Field Values


Information for this section only applies to the transferring hospital.



Records from Transferring Facility






Data Format: [date] single entry Pick list: No Min Value: 01/01/2008 Max Value: Current Date Accepts Null Value: Yes


2017 114

REFER IN INFORMATION SCC County Element R_02 State Element NA TIME OF ARRIVAL National Element NA

Definition

The time the trauma victim arrived at the referring facility.

Field Values











Data Format: [TIME] single entry Pick list: No Min Value: 0:00 Max Value: 23:59 Accepts Null Value: Yes


2017 115

REFER IN INFORMATION SCC County Element R_03 State Element NA DATE OF DISCHARGE National Element NA

Definition

The date the trauma victim was discharged from the referring facility

Field Values











Data Format: [DATE] single entry Pick list: No Min Value: 01/01/2008 Max Value: Current date Accepts Null Value: Yes


2017 116

REFER IN SCC County Element R_04 State Element NA TIME OF DISCHARGE National Element NA

Definition

The time the trauma victim was discharged from the referring facility.

Field Values











Data Format: [TIME] single entry Pick list: No Min Value: 0:00 Max Value: 23:59 Accepts Null Value: Yes


2017 117

REFER IN INFORMATION SCC County Element R_05 State Element NA LENGTH OF STAY National Element NA

Definition

The total amount of time in minutes spent by the patient in the transferring facility.

Field Values

Document in minutes


Auto-calculated








Data Format: [NUMERIC] single entry Pick list: No Min Value: 0 Max Value: NA Accepts Null Value: Yes


2017 118

REFER IN INFORMATION SCC County Element R_06 State Element NA PATIENT MODE OF ARRIVAL National Element NA

Definition

How the patient came to your facility.

Field Values

Transport Mode

7 Fire Department

3 Fixed Wing Ambulance

1 Ground Ambulance

2 Helicopter Ambulance

6 Other

5 Police

4 Private/Public Vehicle/Walk in









Data Format: [numeric] single entry Pick list: Yes non-modifiable Min Value: 1 Max Value: 9 Accepts Null Value: Yes


2017 119

REFER IN INFORMATION SCC County Element R_07 State Element NA REFERRING FACILITY National Element NA

Definition

The name of the facility which transferred the patient to your center.

Field Values

27 Arroyo - Grande Hospital

28 Coalinga Hospital

26 Community Hosp of Monterey Peninsula

5 Community Hospital of Los Gatos

30 Doctors Hospital - San Pablo

29 Doctors Hospital - Modesto

6 Dominican Hospital

7 Eden Medical Center

8 El Camino Hospital

31 Emmanuel

2 Good Samaritan

10 Hazel Hawkins

32 Kaiser - Fremont

33 Kaiser - Hayward

34 Kaiser - NFS

35 Kaiser - Redwood City

17 Kaiser - San Jose Med Ctr

16 Kaiser - Santa Clara

9 Kaiser - South SF

36 Kaweah Delta

37 Kern Medical

38 Lodi Medical

39 Madera Community

40 Marian Medical Center

41 Marin General

12 Mee Memorial

42 Memorial Los Banos

43 Memorial Med. Ctr. - Modesto

44 Mercy Med - Merced

45 Mercy Med - Redding

46 Mills Peninsula

25 Natividad Medical Center

47 North Bay Med Ctr

13 O'Connor Hospital

99 Other

14 Palo Alto Veteran's

48 Queen of the Valley

49 RK Davies


19 Salinas Valley Memorial

68 San Francisco General Hospital

50 San Joaquin General

51 San Mateo Med. Ctr (CHOPE)

52 Santa Cruz County Community Hosp.

53 Santa Rosa Memorial

20 Sequoia Hospital

21 Seton Hospital

54 Sierra View

55 Sonora Regional Medical Center

56 St. Agnes Hospital

57 St. Joseph Hospital

18 St. Louise Hospital

58 St. Rose Hospital

11 Stanford Children's Health

22 Stanford Health Care

59 Sutter - Delta

60 Sutter - Solano

61 Sutter - Tracy

62 Tulare District Hospital

63 Tuolumne General

64 Twin Cities Hospital

65 Vaca Valley Hospital

23 Valley Medical Center

66 Washington Hospital


2017 120

67 Washoe/Renown Hospital

24 Watsonville Community









Data Format: [numeric] single entry Pick list: Yes non-modifiable Min Value: 1 Max Value: 99 Accepts Null Value: Yes


2017 121

REFER IN INFORMATION SCC County Element R_08 State Element NA REFERRING HOSPITAL COMMENTS National Element NA

Definition

Free text area which allows registrar to indicate special information about the transferred

patient.

Field Values

Free text.









Data Format: [character 75] single entry Pick list: No Min Value: NA Max Value: NA Accepts Null Value: Yes


2017 122

REFER IN INFORMATION SCC County Element R_09 State Element NA TRANSFERRED IN National Element NA

Definition

Did the patient come by interfacility transfer.

Field Values

Y - Yes

N - No


Information in this section only applies to a patient who is transferred to your facility

from another acute care facility






Data Format: [Alpha, 1] Pick list: Yes Min Value: NA Max Value: NA Accepts Null Value: Yes


2017 123

REFER IN INFORMATION SCC County Element R_10 State Element NA DIRECT ADMIT National Element NA

Definition

Differentiates a direct admit transfer from an interfacility transfer who goes to the ED.

Field Values

Y - Yes

N - No


Information in this section only applies to a patient who is transferred to your facility

from another acute care facility








2017 124

REFER IN INFORMATION SCC County Element R_11 State Element NA ADMITTING SERVICE National Element NA

Definition

Which service the patient is admitted to.

Field Values

21 Anesthesiology

13 Burn

29 Cardiology

04 Cardiothoracic


26 DDS

05 ENT/OHNS


34 GI

06 General Surgery




27 Neurology

03 Neurosurgery



08 Ophthalmology


02 Orthopedics

30 Pain

23 Pathology



17 Pediatrics

11 Plastic Surgery

24 Psychiatry

25 Radiology

14 Rehab

33 Renal

19 Replant Service

01 Trauma

16 Urology



Information in this section only applies to a patient who is transferred to your facility from

another acute care facility


Patient ED medical record




Data Format: [Numeric, 1] Pick list: Yes Min Value: NA Max Value: NA Accepts Null Value: Yes


2017 125

REFER IN INFORMATION SCC County Element R_12 State Element NA ADMITTING PHYSICIAN National Element NA

Definition

Which physician the patient is admitted to.

Field Values

Pick list developed at each trauma facility that identifies the physicians in that facility

(auto-filled)



another acute care facility






Data Format: [Numeric, 1] Pick list: Yes Min Value: NA Max Value: NA Accepts Null Value: Yes


2017 126

REFER IN INFORMATION SCC County Element R_13 State Element NA ADMIT LOCATION National Element NA

Definition

Specific location in your hospital to which the patient is admitted.

Field Values

05 Died

25 Direct Admit

01 Floor Bed

16 OB Obs

17 Pediatrics

03 Telemetry/Stepdown

04 Home with Services

09 Home without Services

20 Burn Unit

08 ICU

18 PICU

07 Operating Room

30 Pediatric OR

10 Left AMA

14 Mental Health

02 Observation Unit

06 Other

11 Transferred to Another Hospital



another acute care facility.

Readmissions to the Observation Unit will not be included in the registry.








2017 127

REFER IN SCC County Element R_14 State Element NA TRANSFER IN FOR HIGHER LEVEL OF CARE National Element NA

Definition

This differentiates the patients who are sent to your facility because they need a higher level of

care.

Field Values

Y – Yes

N – No



another acute care facility.


Patient records from transferring facility.




Data Format: [Alpha, 1] Pick list: YES Min Value: NA Max Value: NA Accepts Null Value: Yes


2017 128

EMERGENCY DEPARTMENT INFORMATION


2017 129

EMERGENCY DEPARTMENT INFORMATION SCC County Element E_01 State Element ED_01 ED/HOSPITAL ARRIVAL DATE National Element ED_01

Definition

The date the patient arrived to the ED/hospital.

Field Values



If the patient was brought to the ED, enter date patient arrived at ED. If patient was

directly admitted to the hospital, enter date patient was admitted to the hospital.

Used to auto-generate two additional calculated fields: Total EMS Time: (elapsed time

from EMS dispatch to hospital arrival) and Total Length of Hospital Stay (elapsed time

from ED/Hospital Arrival to ED/Hospital Discharge).


ED patient records







0346 3 ED/Hospital Arrival Date is earlier than EMS Dispatch Date

0347 3 ED/Hospital Arrival Date is earlier than EMS Unit Arrival on Scene Date

0348 3 ED/Hospital Arrival Date is earlier than EMS Unit Scene Departure Date

0349 2 ED/Hospital Arrival Date is later than ED Discharge Date

0350 2 ED/Hospital Arrival Date is later than Hospital Discharge Date

0351 3 ED/Hospital Arrival Date is earlier than Date of Birth

0352 3 ED/Hospital Arrival Date should be after 1993

0353 3 ED/Hospital Arrival Date minus Injury Incident Date should be less than 30 days

0354 3 ED/Hospital Arrival Date minus EMS Dispatch Date is greater than 7 days


Data Format: [DATE, 1] Pick list: Yes Min Value: 07/01/2008 Max Value: Current date Accepts Null Value: No


2017 130

EMERGENCY DEPARTMENT INFORMATION SCC County Element E_02 State Element ED_02 ED/HOSPITAL ARRIVAL TIME National Element ED_02

Definition

The time the patient arrived to the ED/hospital.

Field Values

• Relevant value for data element


• If the patient was brought to the ED, enter time patient arrived at ED. If patient was

directly admitted to the hospital, enter time patient was admitted to the hospital

• Used to auto-generate two additional calculated fields: Total EMS Time: (elapsed time from EMS dispatch to hospital arrival) and Total Length of Hospital Stay (elapsed time from ED/Hospital Arrival to ED/Hospital Discharge).


1. ED Records

2. EMS Report Form






0359 4 ED/Hospital Arrival Time is earlier than EMS Dispatch Time

0360 4 ED/Hospital Arrival Time is earlier than EMS Unit Arrival on Scene Time

0361 4 ED/Hospital Arrival Time is earlier than EMS Unit Scene Departure Time

0362 4 ED/Hospital Arrival Date is later than ED Discharge Time

0363 4 ED/Hospital Arrival Date is later than Hospital Discharge Time


Data Format: [TIME, 1] Pick list: No Min Value: 00:01 Max Value: 23:59 Accepts Null Value: No


2017 131

EMERGENCY DEPARTMENT INFORMATION SCC County Element E_03 State Element ED_22 ED DISCHARGE DATE National Element ED_22

Definition

The date the order was written for the patient to be discharged from the ED.

Field Values



Used to auto-generate an additional calculated field: Total ED Time: (elapsed time from ED admit to ED discharge).

The null value “Not Applicable” is used if the patient is directly admitted to the hospital.

If ED Discharge Disposition is 5 Deceased/Expired, then ED Discharge Date is the date of death as indicated on the patient’s death certificate.


1. Physician’s Progress Notes

2. Billing Sheet / Medical Records Coding Summary Sheet 3. Hospital Discharge Summary






0368 4 ED Discharge Date is earlier than EMS Dispatch Date

0369 4 ED Discharge Date is earlier than EMS Unit Arrival on Scene Date

0370 4 ED Discharge Date is earlier than EMS Unit Scene Departure Date

0371 2 ED Discharge Date is earlier than ED/Hospital Arrival Date

0372 2 ED Discharge Date is later than Hospital Discharge Date

0373 3 ED Discharge Date is earlier than Date of Birth

0374 3 ED Discharge Date minus ED/Hospital Arrival Date is greater than 365 days

Data Format: [DATE, 1] Pick list: Yes Min Value: 07/01/2008 Max Value: Current date Accepts Null Value: No


2017 132

EMERGENCY DEPARTMENT INFORMATION SCC County Element E_04 State Element ED_23 ED DISCHARGE TIME National Element ED_23

Definition

The time the order was written for the patient to be discharged from the ED.

Field Values



Used to auto-generate an additional calculated field: Total ED Time (elapsed time from ED admit to ED discharge).

The null value “Not Applicable” is used if the patient is directly admitted to the hospital.

If ED Discharge Disposition is 5 Deceased/Expired, then ED Discharge Time is the time of death as indicated on the patient’s death certificate.


1. ED Records

2. Hospital Record






0378 4 ED Discharge Time is earlier than EMS Dispatch Time

0379 4 ED Discharge Time is earlier than EMS Unit Arrival on Scene Time

0380 4 ED Discharge Time is earlier than EMS Unit Scene Departure Date

0381 4 ED Discharge Time is earlier than ED/Hospital Arrival Time

0382 4 ED Discharge Time is later than Hospital Discharge Time

Data Format: [TIME, 1] Pick list: No Min Value: 00:01 Max Value: 23:59 Accepts Null Value: No


2017 133

EMERGENCY DEPARTMENT INFORMATION SCC County Element E_05 State Element NA ED LENGTH OF STAY National Element NA

Definition

The total time in minutes that the patient was in the Emergency Department.

Field Values

• Auto-calculated based on arrival time and depart time



1. ED Records




Data Format: [NUMERIC] Pick list: No Min Value: 0 Max Value: NA Accepts Null Value: No


2017 134

EMERGENCY DEPARTMENT INFORMATION SCC County Element E_06 State Element NA ED PHYSICIAN National Element NA

Definition

Documents the ED Physician specialist who cared for the patient.

Field Values

• Pick list which is individualized to the facility



1. ED Records




Data Format: [NUMERIC, 1] Pick list: Yes Min Value: NA Max Value: NA Accepts Null Value: No


2017 135

EMERGENCY DEPARTMENT INFORMATION SCC County Element E_07 State Element NA ADMITTING PHYSICIAN National Element NA

Definition

Which physician the patient is admitted to.

Field Values

Pick list developed at each trauma facility that identifies the credentialed physicians in

that facility









2017 136

EMERGENCY DEPARTMENT INFORMATION SCC County Element E_08 State Element NA ADMITTING SERVICE National Element NA

Definition

Which service the patient is admitted to.

Field Values

21 Anesthesiology

13 Burn

29 Cardiology

04 Cardiothoracic


26 DDS

05 ENT/OHNS


34 GI

06 General Surgery




27 Neurology

03 Neurosurgery



08 Ophthalmology


02 Orthopedics

30 Pain

23 Pathology



17 Pediatrics

11 Plastic Surgery

24 Psychiatry

25 Radiology

14 Rehab

33 Renal

19 Replant Service

01 Trauma

16 Urology








Data Format: [NUMERIC, 1] Pick list: Yes Min Value: 1 Max Value: 99 Accepts Null Value: No


2017 137

EMERGENCY DEPARTMENT INFORMATION SCC County Element E_09 State Element ED_20 ED DISCHARGE DISPOSITION National Element ED_20

Definition

The disposition of the patient at the time of discharge from the ED.

Field Values

05 Died

25 Direct Admit

01 Floor Bed

16 OB Obs

17 Pediatrics




13 Institutional Care (SNF, Board and Care)

20 Burn Unit

08 ICU

18 PICU

19 Spinal Cord Acute Care

07 Operating Room

30 Pediatric OR

12 Jail/Police Custody

10 Left AMA

14 Mental Health

02 Observation Unit

06 Other



Readmissions to the Observation Unit will not be included in the registry. (SCC)








0390 2 Field cannot be Not Applicable when Hospital Discharge Date is Not Applicable

0391 2 Field cannot be Not Applicable when Hospital Discharge Date is Not Known/Not Recorded

0392 2 Field cannot be Not Applicable when Hospital Discharge Disposition is Not Applicable

0393 2 Field cannot be Not Applicable when Hospital Discharge Disposition is Not Known/Not Recorded



2017 138

EMERGENCY DEPARTMENT INFORMATION SCC County Element E_10 State Element ED_21 SIGNS OF LIFE National Element ED_21

Definition

Indication of whether patient arrived at the ED/Hospital with signs of life.

Field Values

1 Arrived with NO signs of life

2 Arrived with signs of life


A patient with no signs of life is defined as having none of the following: organized EKG activity, pupillary responses, spontaneous respiratory attempts or movement, and unassisted blood pressure. This usually implies the patient was brought to the ED with CPR in progress.


1. ED Records







0398 3 Field is 1 (Arrived with NO signs of life) when Initial ED/Hospital SBP > 0, Pulse > 0, OR GCS Motor > 1. Please verify.

0399 3 Field is 2 (Arrived with signs of life) when Initial ED/Hospital SBP = 0, Pulse = 0, AND GCS Motor = 1. Please verify.

Data Format: [ALPHA, 1] Pick list: Yes Min Value: 1 Max Value: 2 Accepts Null Value: No


2017 139

EMERGENCY DEPARTMENT INFORMATION SCC County Element E_11 State Element NA VITAL SIGNS DATE National Element NA

Definition

Date of the first recorded vital signs in the ED/hospital.

Field Values




1. ED Records







Data Format: [DATE, 1] Pick list: No

Min Value: 07/01/2008 Max Value: CURRENT DATE Accepts Null Value: No


2017 140

EMERGENCY DEPARTMENT INFORMATION SCC County Element E_12 State Element NA VITAL SIGNS TIME National Element NA

Definition

Time of the first recorded vital signs in the ED/hospital.

Field Values




1. ED Records







Data Format: [TIME, 1] Pick list: No

Min Value: 00:00 Max Value: 23:59 Accepts Null Value: No


2017 141

EMERGENCY DEPARTMENT INFORMATION SCC County Element E_13 State Element ED_04 INITIAL ED/HOSPITAL PULSE RATE National Element ED_04

Definition

First recorded pulse in the ED/hospital (palpated or auscultated) within 30 minutes or less of

ED/hospital arrival (expressed as a number per minute).

Field Values



Please note that first recorded/hospital vitals do not need to be from the same assessment.

Measurement recorded must be without the assistance of CPR or any type of mechanical chest compression device. For those patients who are receiving CPR or any type of mechanical chest compressions, report the value obtained while compressions are paused.


1. ED Records




0406 1 Invalid valid


0408 3 Pulse rate exceeds the max of 299


Data Format: [NUMERIC, 1] Pick list: No Min Value: NA Max Value: NA Accepts Null Value: No


2017 142

EMERGENCY DEPARTMENT INFORMATION SCC County Element E_14 State Element ED_06 INITIAL ED/HOSPITAL RESPIRATORY RATE National Element ED_06

Definition

First recorded respiratory rate in the ED/hospital within 30 minutes or less of ED/hospital arrival

(expressed as a number per minute).

Field Values



• Used to calculate Revised Trauma Score - ED (adult & pediatric)

• If available, complete additional field: Initial ED/Hospital Respiratory Assistance.



1. ED Records




0410 1 Invalid value. RR cannot be > 99 for age in years >=6 OR RR cannot be > 120 for age in years < 6. If age and age units are not valued, RR cannot be > 120.


0412 3 Invalid, out of range. RR cannot be > 99 and <=120 for age in years < 6. If age and age units are not valued, RR cannot be > 99.


Data Format: [NUMERIC, 1] Pick list: No Min Value: NA Max Value: NA Accepts Null Value: Yes


2017 143

EMERGENCY DEPARTMENT INFORMATION SCC County Element E_15 State Element ED_07 INITIAL ED/HOSPITAL RESPIRATORY ASSISTANCE National Element ED_07

Definition

Determination of respiratory assistance associated with the initial ED/hospital respiratory rate

within 30 minutes or less of ED/hospital arrival.

Field Values

A Assisted

U Unassisted


Only completed if a value is provided for Initial ED/Hospital Respiratory Rate.

Respiratory Assistance is defined as mechanical and/or external support of respiration.


The null value “Not Applicable” is used if “Initial ED/Hospital Respiratory Rate” is “Not Known/Not Recorded.”


1. ED Records






Data Format: [ALPHA, 1] Pick list: No Min Value: NA Max Value: NA Accepts Null Value: Yes


2017 144

EMERGENCY DEPARTMENT INFORMATION SCC County Element E_16 State Element ED_08 INITIAL ED/HOSPITAL OXYGEN SATURATION National Element ED_08

Definition

First recorded oxygen saturation in the ED/hospital within 30 minutes or less of ED/hospital

arrival (expressed as a percentage).

Field Values



If available, complete additional field: Initial ED/Hospital Supplemental Oxygen.



1. ED Records




0416 1 Pulse oximetry is outside the valid range of 0 - 100



Data Format: [NUMERIC, PERCENTAGE 1] Pick list: No Min Value: NA Max Value: NA Accepts Null Value: Yes


2017 145

EMERGENCY DEPARTMENT INFORMATION SCC County Element E_17 State Element ED_09 INITIAL ED/HOSPITAL SUPPLEMENTAL OXYGEN National Element ED_09

Definition

Determination of the presence of supplemental oxygen during assessment of initial

ED/hospital oxygen saturation level within 30 minutes or less of ED/hospital arrival.

Field Values

• 1 Yes

• 2 No


Only completed if a value is provided for Initial ED/Hospital Oxygen Saturation, otherwise report as “Not Applicable”.



1. ED Records






Data Format: [ALPHA/NUMERIC, 1] Pick list: Yes Min Value: NA Max Value: NA Accepts Null Value: Yes


2017 146

EMERGENCY DEPARTMENT INFORMATION SCC County Element E_18 State Element ED_03 INITIAL ED/HOSPITAL SYSTOLIC BLOOD PRESSURE National Element ED_03

Definition

First recorded systolic blood pressure in the ED/hospital within 30 minutes or less of

ED/hospital arrival.

Field Values





Measurement recorded must be without the assistance of CPR or any type of mechanical chest compression device. For those patients who are receiving CPR or any type of mechanical chest compressions, report the value obtained while compressions are paused.


1. ED Records






0423 3 SBP value exceeds the max of 300


Data Format: [NUMERIC, 1] Pick list: No Min Value: 0 Max Value: 300 Accepts Null Value: Yes


2017 147

EMERGENCY DEPARTMENT INFORMATION SCC County Element E_19 State Element NA INITIAL ED/HOSPITAL DIASTOLIC BLOOD PRESSURE National Element NA

Definition

First recorded diastolic blood pressure in the ED/hospital within 30 minutes or less of


Field Values






1. ED Records






0427 3 DBP value exceeds the max of 300



2017 148

EMERGENCY DEPARTMENT INFORMATION SCC County Element E_20 State Element ED_10 INITIAL ED/HOSPITAL GCS - EYE National Element ED_10

Definition

First recorded Glasgow Coma Score (Eye) in the ED/hospital within 30 minutes or less of


Field Values

Score Qualifier

4 Opens eyes spontaneously

3 Opens eyes in response to verbal stimulation

2 Opens eyes in response to painful stimulation

1 No eye movement when assessed


Used to calculate Overall GCS – ED Score.

If a patient does not have a numeric GCS score recorded, but written documentation closely (or directly) relates to verbiage describing a specific level of functioning within the GCS scale, the appropriate numeric score may be listed. E.g. the chart indicates: “patient pupils are PERRL,” an Eye GCS of 4 may be recorded, IF there is no other contradicting documentation.



1. ED Records







Data Format: [NUMERIC, 1] Pick list: Yes Min Value: NA Max Value: NA Accepts Null Value: Yes


2017 149

EMERGENCY DEPARTMENT INFORMATION SCC County Element E_21 State Element ED_11 INITIAL ED/HOSPITAL GCS – VERBAL National Element ED_11

Definition

First recorded Glasgow Coma Score (Verbal) within 30 minutes of less of ED/hospital arrival.

Field Values


5 Smiles, oriented to sounds, follows objects, interacts

4 Cries but is consolable, inappropriate interactions

3 Inconsistently consolable, moaning

2 Inconsolable, agitated

1 No vocal response

Adult:

5 Oriented

4 Confused

3 Inappropriate words

2 Incomprehensible sounds

1 No verbal response



If patient is intubated then the GCS Verbal score is equal to 1.

If a patient does not have a numeric GCS score recorded, but written documentation closely (or directly) relates to verbiage describing a specific level of functioning within the GCS scale, the appropriate numeric score may be listed. E.g. the chart indicates: “patient is oriented to person place and time,” a Verbal GCS of 5 may be recorded, IF there is no other contradicting documentation.



1. ED Records







Data Format: [NUMERIC, 1] Pick list: YES Min Value: NA Max Value: NA Accepts Null Value: YES


2017 150

EMERGENCY DEPARTMENT INFORMATION SCC County Element E_22 State Element ED_12 INITIAL ED/HOSPITAL GCS – MOTOR National Element ED_12

Definition

First recorded Glasgow Coma Score (Motor) within 30 minutes or less of ED/hospital arrival.

Field Values

Pediatric (≤2 years):

6 Appropriate response to stimulation

5 Localizing pain


3 Flexion to pain

2 Extension to pain

1 No motor response

Adult:

6 Obeys commands

5 Localizing pain


3 Flexion to pain

2 Extension to pain

1 No motor response



If a patient does not have a numeric GCS score recorded, but written documentation closely (or directly) relates to verbiage describing a specific level of functioning within the GCS scale, the appropriate numeric score may be listed. E.g. the chart indicates: “patient withdraws from a painful stimulus,” a Motor GCS of 4 may be recorded, IF there is no other contradicting documentation.



1. ED Records 2. Physician’s Progress Notes






Data Format: [NUMERIC, 1] Pick list: Yes Min Value: NA Max Value: NA Accepts Null Value: Yes


2017 151

EMERGENCY DEPARTMENT INFORMATION SCC County Element E_23 State Element ED_13 INITIAL ED/HOSPITAL GCS - TOTAL National Element ED_13

Definition

First recorded Glasgow Coma Score (total) within 30 minutes or less of ED/hospital arrival.

Field Values



• Is auto-calculated if components are entered, or total can be hand-entered if

components not available

• If a patient does not have a numeric GCS recorded, but documentation related to their level of consciousness such as “AAOx3”, “awake alert and oriented,” or “patient with normal mental status,” interpret this as GCS of 15 IF there is no other contraindicating documentation.



1. ED Records




0437 1 GCS Total is outside the valid range of 3 - 15

0438 4 Initial ED/Hospital GCS – Total does not equal the sum of Initial ED/Hospital GCS – Eye, Initial ED/Hospital GCS – Verbal, and Initial ED/Hospital GCS - Motor



Data Format: [NUMERIC, AUTO-CALCULATED1] Pick list: No Min Value: NA Max Value: NA Accepts Null Value: Yes


2017 152

EMERGENCY DEPARTMENT INFORMATION SCC County Element E_24 State Element ED_14 INITIAL ED/HOSPITAL GCS ASSESSMENT QUALIFIERS National Element ED_14

Definition

Documentation of factors potentially affecting the first assessment of GCS within 30

minutes or less of ED/hospital arrival.

Field Values

1. Patient Chemically Sedated or Paralyzed 2. Obstruction to the Patient’s Eye 3. Patient Intubated 4. Valid GCS: Patient was not sedated, not intubated, and did not have obstruction to the

eye


Identifies treatments given to the patient that may affect the first assessment of GCS.

This field does not apply to self-medications the patient may administer (i.e. ETOH,

prescriptions, etc.).

If an intubated patient has recently received an agent that results in neuromuscular

blockade such that a motor or eye response is not possible, then the patient should be

considered to have an exam that is not reflective of their neurologic status and the

chemical sedation modifier should be selected.

Neuromuscular blockade is typically induced following the administration of agent like

succinylcholine, mivacurium, rocuronium, (cis)atracurium, vecuronium, or pancuronium.

While these are the most common agents, please review what might be typically used

in your center so it can be identified in the medical record.

Each of these agents has a slightly different duration of action, so their effect on the

GCS depends on when they were given. For example, succinylcholine’s effects last for

only 5-10 minutes.

Please note that first recorded/hospital vitals do not need to be from the same

assessment.

Check all that apply. Data Source Hierarchy

1. ED Records






Data Format: [ALPHA, 1] Pick list: No Min Value: NA Max Value: NA Accepts Null Value: Yes


2017 153

EMERGENCY DEPARTMENT INFORMATION SCC County Element E_25 State Element ED_15 INITIAL ED/HOSPITAL HEIGHT National Element ED_15

Definition

First recorded height upon ED/hospital arrival.

Field Values



Recorded in centimeters.

May be based on family or self-report.



1. Triage/Trauma/Hospital Flow Sheet

2. Nurses Notes/Flow Sheet 3. Pharmacy Record





0445 3 Height exceeds the max of 244 (cm)




2017 154

EMERGENCY DEPARTMENT INFORMATION SCC County Element E_26 State Element ED_16 INITIAL ED/HOSPITAL WEIGHT National Element ED_16

Definition

Measured or estimated baseline weight.

Field Values



Recorded in kilograms.

May be based on family or self-report.



1. Triage/Trauma/Hospital Flow Sheet

2. Nurses Notes/Flow Sheet 3. Pharmacy Record





0449 3 Weight exceeds the max of 907 (kg)




2017 155

EMERGENCY DEPARTMENT INFORMATION SCC County Element E_27 State Element NA INITIAL ED/HOSPITAL REVISED TRAUMA SCORE National Element NA

Definition

The Revised Trauma Score (RTS) is a physiologic scoring system, designed for use in based on the initial vital signs of a patient. A lower score indicates a higher severity of injury

Field Values

Auto-calculated based on the patient’s total GCS, the patient’s RR and the patient’s systolic BP



PCR

ED medical Record





Data Format: [NUMERIC/AUTO-CALCULATED,1] Pick list: No Min Value: NA Max Value: NA Accepts Null Value: Yes


2017 156

EMERGENCY DEPARTMENT INFORMATION SCC County Element E_28 State Element ED_05 INITIAL ED/HOSPITAL TEMPERATURE National Element ED_05

Definition

First recorded temperature (in degrees Celsius [centigrade]) in the ED/hospital within 30

minutes or less of ED/hospital arrival.

Field Values





1. ED Records






0455 3 Temperature exceeds the max of 45.0 Celsius


Data Format: [NUMERIC,1] Pick list: No

Min Value: NA Max Value: NA Accepts Null Value: Yes


2017 157

EMERGENCY DEPARTMENT INFORMATION SCC County Element E_ State Element ED_17 DRUG SCREEN National Element ED_17

Definition

First recorded positive drug screen results within 24 hours after first hospital encounter (select

all that apply). Field Values

1. AMP (Amphetamine) 9. OXY

2. BAR (Barbiturate) 10. PCP (Phencyclidine

3. BZO (Benzodiazepines) 11. TCA (Tricyclic Antidepressant)

4. COC (Cocaine) 12. THC (Cannabinoid)

5. mAMP (Methamphetamine) 13. Other

6. MDMA (Ecstasy) 14. None

7. MTD (Methadone) 15. Not Tested

8. OPI (Opioid)


Record positive drug screen results within 24 hours after first hospital encounter, at

either your facility or the transferring facility.

“None” is reported for patients whose only positive results are due to drugs

administered at any facility (or setting) treating this patient event, or for patients who

were tested and had no positive results.

If multiple drugs are detected, only report drugs that were not administered at any

facility (or setting) treating this patient event.


1. Lab Results

2. Transferring Facility Records






Data Format: [NUMERIC,1] Pick list: Yes Min Value: NA Max Value: NA Accepts Null Value: Yes


2017 158

EMERGENCY DEPARTMENT INFORMATION SCC County Element E_ State Element ED_18 ALCOHOL SCREEN National Element ED_18

Definition

A blood alcohol concentration (BAC) test was performed on the patient within 24 hours after

first hospital encounter. Field Values

5. Yes 6. No


Alcohol screen may be administered at any facility, unit, or setting treating this patient

event.


1. Lab Results







Data Format: [NUMERIC,1] Pick list: Yes Min Value: NA Max Value: NA Accepts Null Value: Yes


2017 159

EMERGENCY DEPARTMENT INFORMATION SCC County Element E_ State Element ED_19 ALCOHOL SCREEN RESULTS National Element ED_19

Definition

First recorded blood alcohol concentration (BAC) results within 24 hours after first hospital

encounter. Field Values

Relevant value for data element.


Collect as X.XX standard lab value (e.g. 0.08).

Record BAC results within 24 hours after first hospital encounter, at either your facility

or the transferring facility.

The null value “Not Applicable” is used for those patients who were not tested.


1. Lab Results






0465 2 Field cannot be Not Applicable when Alcohol Screen is 1 (Yes)

Data Format: [NUMERIC,1] Pick list: No Min Value: NA Max Value: NA Accepts Null Value: Yes


2017 160

EMERGENCY DEPARTMENT SCC County Element E_31 State Element NA INTERVENTIONS National Element NA

Definition

Describes all of the interventions that are provided to the patient in the ED

Field Values

00 None

37 Massive Transfusion

46 Pelvic Binder

99 Other



1. ED Records

2. Physician’s Progress Notes Associated Edit Checks




Data Format: [NUMERIC,1] Pick list: YES Min Value: NA Max Value: NA Accepts Null Value: YES


2017 161

EMERGENCY DEPARTMENT SCC County Element E_32 State Element NA ED COMMENTS National Element NA

Definition

Free text area for clarification comments.

Field Values

Text relevant to the incident



1. ED records




Data Format: [ALPHA,1] Pick list: No Min Value: NA Max Value: NA Accepts Null Value: Yes


2017 162

EMERGENCY DEPARTMENT SCC County Element E_33 State Element NA TIME TO FIRST CT SCAN National Element NA

Definition

The calculated time to first CT Scan.

Field Values

Auto Calculated in minutes



1. Radiology Records

2. ED Records






Data Format: [TIME,1] Pick list: Yes Min Value: 00:01 Max Value: 23:59 Accepts Null Value: No


2017 163

TRAUMA TEAM INFORMATION


2017 164

TRAUMA TEAM INFORMATION SCC County Element TT_01 State Element NA ACTIVATION LEVEL National Element NA

Definition

The code used for the level of trauma team activation. Santa Clara County Trauma Centers all

use a tiered level of trauma team response.

Field Values

MAJ Major

MIN Minor

CON Consult

CSS Consult Sub-Specialty



1. ED Records





Data Format: [ALPHA,1] Pick list: Yes Min Value: NA Max Value: NA Accepts Null Value: Yes


2017 165

TRAUMA TEAM INFORMATION SCC County Element TT_02 State Element NA ACTIVATION DATE National Element NA

Definition

The date the patient came to your facility.

Field Values


If the patient comes to the ED, use the date of arrival at the ED.

If the patient is a direct admit, use the date of admission to the hospital


1. ED Records







Data Format: [NUMERIC DATE,1] Pick list: No

Min Value: 07/01/2008 Max Value: Current Date Accepts Null Value: Yes


2017 166

TRAUMA TEAM INFORMATION SCC County Element TT_03 State Element NA ACTIVATION TIME National Element NA

Definition

The time of the trauma team activation.

Field Values




1. ED Records







Data Format: [NUMERIC TIME,1] Pick list: No

Min Value: 00:01 Max Value: 23:59 Accepts Null Value: Yes


2017 167

TRAUMA TEAM INFORMATION SCC County Element TT_04 State Element NA ROLE National Element NA

Definition

The code describing the trauma team role.

Field Values

TRS Trauma Surgeon LAB Laboratory

EDP ED Physician SSE Social Services

PRN Primary RN SUP Nursing Supervisor

RES Respiratory Therapy SEC Security

ORN OR Nurse OTH Other Specialty

REC Recorder SRN Specialty RN

RAD Radiology TCN Trauma Charge Nurse

TR4 Trauma Resident



1. ED Records




Data Format: [ALPHA,1] Pick list: Yes

Min Value: NA Max Value: NA Accepts Null Value: Yes


2017 168

TRAUMA TEAM INFORMATION SCC County Element TT_05 State Element NA MEMBER ID National Element NA

Definition

Lists which category of personnel is involved.

Field Values

Trauma Attending

ED (ED MD)

RN (Trauma RN)






Data Format: [ALPHA,1] Pick list: Yes Min Value: NA Max Value: NA Accepts Null Value: No


2017 169

TRAUMA TEAM INFORMATION SCC County Element TT_06 State Element NA LONG NAME National Element NA

Definition

Lists the name of the person responding to the incident.

Field Values

• Hospital developed pick list








2017 170

TRAUMA TEAM INFORMATION SCC County Element TT_07 State Element ED_01 PATIENT ARRIVED National Element ED_01

Definition

The time the patient arrived to the Trauma Suite.

Field Values



• If the patient was brought to the ED, enter time patient arrived at ED. If patient was

directly admitted to the hospital, enter time patient was admitted to the hospital.

• Used to calculate Total EMS Time and Total Length of Hospital Stay.


1. ED Records

2. EMS Report Form






Data Format: [NUMERIC,1] Pick list: No Min Value: 00:01 Max Value: 23:59 Accepts Null Value: No


2017 171

TRAUMA TEAM INFORMATION SCC County Element TT_08 State Element NA TRAUMA MEMBER ARRIVED National Element NA

Definition

The time the Trauma Team arrived to the Trauma Suite.

Field Values




1. ED Records

2. EMS Report Form






Data Format: [NUMERIC,1] Pick list: No Min Value: 00:01 Max Value: 23:59 Accepts Null Value: No


2017 172

TRAUMA TEAM INFORMATION SCC County Element TT_09 State Element NA RESPONSE TIME National Element NA

Definition

The time the Trauma Team arrived to the Trauma Suite.

Field Values




1. ED Records

2. EMS Report Form






Data Format: [TIME,1] Pick list: No Min Value: 00:01 Max Value: 23:59 Accepts Null Value: No


2017 173

TRAUMA TEAM INFORMATION SCC County Element TT_10 State Element NA TIMELY National Element NA

Definition

Identifies whether or not the trauma team assembles in a timely manner.

Field Values

• Y – Yes

N - No


• Auto-calculated field


1. ED Records

2. EMS Report Form






2017 174

CONSULTS INFORMATION


2017 175

TRAUMA TEAM-CONSULTS INFORMATION SCC County Element TT_11 State Element NA DATE CALLED National Element NA

Definition

The date the consult was requested.

Field Values



1. ED Records

2. EMS Report Form








2017 176

TRAUMA TEAM-CONSULTS INFORMATION SCC County Element TT_12 State Element NA TIME CALLED National Element NA

Definition

The time the consult was requested.

Field Values



1. ED Records

2. EMS Report Form






Data Format: [TIME,1] Pick list: No Min Value: 00:01 Max Value: 23:59 Accepts Null Value: No


2017 177

TRAUMA TEAM-CONSULTS INFORMATION SCC County Element TT_13 State Element NA DATE RESPONDED National Element NA

Definition

The date the consultant responded to the trauma patient.

Field Values



1. ED Records

2. EMS Report Form






Data Format: [DATE,1] Pick list: No

Min Value: 07/01/2008 Max Value: CURRENT DATE Accepts Null Value: No


2017 178

TRAUMA TEAM-CONSULTS INFORMATION SCC County Element TT_14 State Element NA TIME RESPONDED National Element NA

Definition

The time the consultant responded

Field Values



1. ED Records

2. EMS Report Form






Data Format: [TIME,1] Pick list: No

Min Value: 00:01 Max Value: 23:59 Accepts Null Value: No


2017 179

TRAUMA TEAM-CONSULTS INFORMATION SCC County Element TT_15 State Element NA SERVICE National Element NA

Definition

The consult service requested.

Field Values

21 Anesthesiology

13 Burn

29 Cardiology

04 Cardiothoracic


26 DDS

05 ENT/OHNS


34 GI

06 General Surgery




27 Neurology

03 Neurosurgery



08 Ophthalmology


02 Orthopedics

30 Pain

23 Pathology



17 Pediatrics

11 Plastic Surgery

24 Psychiatry

25 Radiology

14 Rehab

33 Renal

19 Replant Service

01 Trauma

16 Urology



Select from the above pick list for consult service


1. ED Records

2. EMS Report Form




Data Format: [NUMERIC,1] Pick list: Yes Min Value: 00 Max Value: 99 Accepts Null Value: No


2017 180

TRAUMA TEAM-CONSULTS INFORMATION SCC County Element TT_16 State Element NA PHYSICIAN National Element NA

Definition

The type of physician performed the consult.

Field Values

Trauma Center created pick list based on type of physician who consulted


Date Source Hierarchy

1. ED record




Data Format: [NUMERIC,1] Pick list: Yes Min Value: NA Max Value: NA Accepts Null Value: No


2017 181

LABORATORY INFORMATION


2017 182

LABORATORY INFORMATION SCC County Element LAB_01 State Element NA

TESTING DONE National Element NA

Definition

The results of all lab studies completed in the ED for a trauma patient. If none done, indicate

NA in the first date field.

Field Values

Date: indicate the date in the following format: DD/MM/YYYY

Value: indicate the value in each column under each of the following headings:

Blood ETOH

HGB

HCT

BD

Lactate

INR


ED record

Lab results

MD Documentation






Data Format: [ALPHA,1] Pick list: No Min Value: NA Max Value: NA Accepts Null Value: Yes


2017 183

LABORATORY INFORMATION SCC County Element LAB_02 State Element NA TOXICOLOGY National Element NA

Definition

If toxicology is positive, drugs known to be abused (not therapeutic) by patient at time of

injury.

Field Values

Testing for the following drugs:

Amphetamines Narcotics-Opiates

Barbiturates None

Benzodiazepines Other

Cocaine PCP

Methamphetamine Cannabis, THC, Marijuana (include medical)


Use the following data elements for documentation:

1 No Not Tested

2 No Confirmed by test

3 Yes Test (trace levels)

4 Yes Test (beyond legal limits)


1. Lab results

2. ED Records






2017 184

INPATIENT INFORMATION


2017 185

INPATIENT INFORMATION SCC County Element IP_01 State Element NA LOCATION National Element NA

Definition

The locations to which patient is admitted.

Field Values

05 Died

25 Direct Admit

01 Floor Bed

16 OB Obs

17 Pediatrics




13 Institutional Care (SNF, Board and Care)

20 Burn Unit

08 ICU

18 PICU


07 Operating Room

30 Pediatric OR

12 Jail/Police Custody

10 Left AMA

14 Mental Health

02 Observation Unit

06 Other



Readmissions to the Observation Unit will not be included in the registry.


1. ED Records






2017 186

INPATIENT INFORMATION SCC County Element IP_02 State Element NA DATE IN National Element NA

Definition

The date the patient became an inpatient at your facility.

Field Values



If the patient arrives by interfacility transport the date selected is the date the patient

comes to your facility.


ED Records

Patient Care Record






Data Format: [date, 8] Pick list: No Min Value: 07/01/2008 Max Value: Current Date Accepts Null Value: Yes


2017 187

INPATIENT INFORMATION SCC County Element IP_03 State Element NA TIME IN National Element NA

Definition

The time the patient became an inpatient at your facility.

Field Values




ED Records

Patient Care Record






Data Format: [time, 4] Pick list: No Min Value: 00:01 Max Value: 23:59 Accepts Null Value: Yes


2017 188

INPATIENT INFORMATION SCC County Element IP_04 State Element NA DATE OUT National Element NA

Definition

The date the patient left the inpatient location.

Field Values




ED Records

Patient Care Record






Data Format: [date, 8] Pick list: No Min Value: 07/01/2008 Max Value: Current Date Accepts Null Value: Yes


2017 189

INPATIENT INFORMATION SCC County Element IP_05 State Element NA TIME OUT National Element NA

Definition

The time the patient left the location.

Field Values




ED Records

Patient Care Record






Data Format: [time, 4] Pick list: No Min Value: 00:01 Max Value: 23:59 Accepts Null Value: Yes


2017 190

INPATIENT INFORMATION SCC County Element IP_06 State Element NA LENGTH OF STAY National Element NA

Definition

The length of time the patient spent in the inpatient unit.

Field Values

Auto calculated in minutes.



ED Records

Patient Care Record




Data Format: [numeric, 4] Pick list: No Min Value: 0 Max Value: NA Accepts Null Value: Yes


2017 191

INPATIENT INFORMATION SCC County Element IP_07 State Element NA VENT DAYS National Element NA

Definition

The cumulative amount of time spent on the ventilator. Each partial or full day should be

measured as one calendar day.

Field Values


Manually calculated (SCC)


Excludes mechanical ventilation time associated with OR procedures.

Non-invasive means of ventilator support (CPAP or BIPAP) should not be considered in

the calculation of ventilator days.

Recorded in full day increments with any partial calendar day counted as a full calendar

day.

The calculation assumes that the date and time of starting and stopping Ventilator

episode are recorded in the patient’s chart.

If any dates are missing then a Total Vent Days cannot be calculated.

At no time should the Total Vent Days exceed the Hospital LOS.

The null value “Not Applicable” is used if the patient was not on the ventilator according

to the above definition.

Example # Start Date Start Time Stop Date Stop Time LOS

A. 01/01/11 01:00 01/01/11 04:00 1 day (one calendar day)

B. 01/01/11 01:00 01/01/11 04:00

01/01/11 16:00 01/01/11 18:00 1 day (2 episodes within one calendar day)

C. 01/01/11 01:00 01/01/11 04:00

01/02/11 16:00 01/02/11 18:00 2 days (episodes on 2 separate calendar days)

D. 01/01/11 01:00 01/01/11 16:00


E. 01/01/11 01:00 01/01/11 16:00


F. 01/01/11 Unknown 01/01/11 16:00 1 day

G. 01/01/11 Unknown 01/02/11 16:00 2 days (patient was on Vent on 2 separate calendar days)

H. 01/01/11 Unknown 01/02/11 16:00


2017 192

01/02/11 18:00 01/02/11 Unknown 2 days (patient was on Vent on 2 separate calendar days)

I. 01/01/11 Unknown 01/02/11 16:00

01/02/11 18:00 01/02/11 20:00 2 days (patient was on Vent on 2 separate calendar days)

J. 01/01/11 Unknown 01/02/11 16:00



ED Records

Patient Care Record



0524 1 Total Ventilator Days is outside the valid range of 1 – 575


0526 4 Total Ventilator Days should not be greater than the difference between ED/Hospital Arrival Date and Hospital Discharge Date

0527 4 Value is greater than 365, please verify this is correct

Data Format: [numeric, 4] Pick list: No Min Value: 0 Max Value: NA Accepts Null Value: No


2017 193

INPATIENT INFORMATION SCC County Element IP_08 State Element NA ICU INITIAL TEMPERATURE National Element NA

Definition

The temperature of the patient upon initial admission to the unit.

Field Values

Relevant to the data element


In units C


Patient Care Record




Data Format: [numeric, 3] Pick list: No Min Value: 90 Max Value: 107 Accepts Null Value: Yes


2017 194

INPATIENT INFORMATION SCC County Element IP_09 State Element O_01 TOTAL ICU LENGTH OF STAY National Element O_01

Definition

The cumulative amount of time spent in the ICU. Each partial or full day should be measured as

one calendar day.

Field Values


Auto-calculated (SCC)



day.

The calculation assumes that the date and time of starting and stopping an ICU episode

are recorded in the patient’s chart.

If any dates are missing then a LOS cannot be calculated.

If patient has multiple ICU episodes on the same calendar day, count that day as one

calendar day.

At no time should the ICU LOS exceed the Hospital LOS.

The null value “Not Applicable” is used if the patient had no ICU days according to the

above definition.



B. 01/01/11 01:00 01/01/11 04:00


C. 01/01/11 01:00 01/01/11 04:00


D. 01/01/11 01:00 01/01/11 16:00


E. 01/01/11 01:00 01/01/11 16:00


F. 01/01/11 Unknown 01/01/11 16:00 1 day

G. 01/01/11 Unknown 01/02/11 16:00 2 days (patient was in ICU on 2 separate calendar days)

H. 01/01/11 Unknown 01/02/11 16:00

01/02/11 18:00 01/02/11 Unknown 2 days (patient was in ICU on 2 separate calendar days)


2017 195

I. 01/01/11 Unknown 01/02/11 16:00

01/02/11 18:00 01/02/11 20:00 2 days (patient was in ICU on 2 separate calendar days)

J. 01/01/11 Unknown 01/02/11 16:00

01/03/11 18:00 01/03/11 20:00 3 days (patient was in ICU on 3 separate calendar days)

K. Unknown Unknown 01/02/11 16:00

01/03/11 18:00 01/03/11 20:00 Unknown (can’t compute total)




0529 1 Total ICU Length of Stay is outside the valid range of 1 - 575


0531 3 Total ICU Length of Stay is greater than the difference between ED/Hospital Arrival Date and Hospital Discharge Date


Data Format: [numeric, ] Pick list: No Min Value: NA Max Value: NA Accepts Null Value: Yes


2017 196

INPATIENT INFORMATION SCC County Element IP_10 State Element NA NON-ICU VENTILATOR DAYS National Element NA

Definition

Length of time that patient is on the ventilator.

Field Values

Auto-Calculated in Days






Data Format: [auto-calculated] Pick list: No Min Value: NA Max Value: NA Accepts Null Value: Yes


2017 197

INPATIENT INFORMATION SCC County Element IP_11 State Element NA ICU VENTILATOR DAYS National Element NA

Definition

The length of time the patient is on the ventilator in the ICU.

Field Values

Auto-Calculated in Days






Data Format: [auto-calculated] Pick list: No Min Value: NA Max Value: NA Accepts Null Value: Yes


2017 198

INPATIENT INFORMATION SCC County Element IP_12 State Element O_02 TOTAL VENTILATOR DAYS National Element O_02

Definition

The cumulative amount of time spent on the ventilator. Each partial or full day should be

measured as one calendar day.

Field Values


Auto-Calculated (SCC)


Excludes mechanical ventilation time associated with OR procedures.

Non-invasive means of ventilator support (CPAP or BIPAP) should not be considered in

the calculation of ventilator days.


day.

The calculation assumes that the date and time of starting and stopping Ventilator

episode are recorded in the patient’s chart.

If any dates are missing then a Total Vent Days cannot be calculated.

At no time should the Total Vent Days exceed the Hospital LOS.

The null value “Not Applicable” is used if the patient was not on the ventilator according

to the above definition.



B. 01/01/11 01:00 01/01/11 04:00


C. 01/01/11 01:00 01/01/11 04:00


D. 01/01/11 01:00 01/01/11 16:00


E. 01/01/11 01:00 01/01/11 16:00


F. 01/01/11 Unknown 01/01/11 16:00 1 day

G. 01/01/11 Unknown 01/02/11 16:00 2 days (patient was on Vent on 2 separate calendar days)

H. 01/01/11 Unknown 01/02/11 16:00


2017 199

01/02/11 18:00 01/02/11 Unknown 2 days (patient was on Vent on 2 separate calendar days)

I. 01/01/11 Unknown 01/02/11 16:00


J. 01/01/11 Unknown 01/02/11 16:00



ED Records

Patient Care Record



0535 1 Total Ventilator Days is outside the valid range of 1 - 575


0537 4 Total Ventilator Days should not be greater than the difference between ED/Hospital Arrival Date and Hospital Discharge Date


Data Format: [numeric, 4] Pick list: No Min Value: 0 Max Value: NA Accepts Null Value: No


2017 200

HOSPITAL PROCEDURE INFORMATION


2017 201

HOSPITAL PROCEDURE INFORMATION SCC County Element PR_01 State Element NA

LOCATION National Element NA

Definition

Location of procedures conducted during hospital stay.

Field Values

19 Angio

13 Burn unit

20 CT

17 ED

11 ICU

15 Interventional radiology

21 MRI

03 Med/Surg

22 NICU

06 OB Obs

01 OR

02 Obs Unit

08 PICU

07 Pediatric Floor

30 Pediatric OR

16 Radiology

14 Rehab

23 SICU


09 Step Down

10 TCU

25 Telemetry

18 Trauma Room


Enter null values as applicable


Patient Care Record




Data Format: [numeric, 2] Pick list: Yes Min Value: NA Max Value: NA Accepts Null Value: Yes


2017 202

HOSPITAL PROCEDURE INFORMATION SCC County Element PR_02 State Element NA OR # National Element NA

Definition

Identify the number of operative procedures performed during hospital stay.

Field Values



Enter null value if applicable


Patient care record




Data Format: [numeric, 2] Pick list: No Min Value: NA Max Value: NA Accepts Null Value: Yes


2017 203

HOSPITAL PROCEDURE INFORMATION SCC County Element PR_03 State Element HP_03 HOSPITAL PROCEDURE START DATE National Element HP_03

Definition

The date operative and selected non-operative procedures were performed.

Field Values




1. OR Records

2. Radiology Records 3. ED Records 4. Progress Notes




0542 1 Date is out of range

0543 4 Hospital Procedure Start Date is earlier than EMS Dispatch Date

0544 4 Hospital Procedure Start Date is earlier than EMS Unit Arrival on Scene Date

0545 4 Hospital Procedure Start Date is earlier than EMS Unit Scene Departure Date

0546 4 Hospital Procedure Start Date is earlier than ED/Hospital Arrival Date

0547 4 Hospital Procedure Start Date is later than Hospital Discharge Date

0548 4 Hospital Procedure Start Date is earlier than Date of Birth




2017 204

HOSPITAL PROCEDURE INFORMATION SCC County Element PR_04 State Element HP_04 HOSPITAL PROCEDURE START TIME National Element HP_04

Definition

The time operative and selected non-operative procedures were performed.

Field Values



Procedure start time is defined as the time the incision was made (or the procedure started).

If distinct procedures with the same procedure code are performed, their start times must be different.


1. Radiology readings / Lab results

2. ED Records





0552 4 Hospital Procedure Start Time is earlier than EMS Dispatch Time

0553 4 Hospital Procedure Start Time is earlier than EMS Unit Arrival on Scene Time

0554 4 Hospital Procedure Start Time is earlier than EMS Unit Scene Departure Time

0555 4 Hospital Procedure Start Time is earlier than ED/Hospital Arrival Time

0556 4 Hospital Procedure Start Time is later than Hospital Discharge Time




2017 205

HOSPITAL PROCEDURE INFORMATION SCC County Element PR_05 State Element NA ELAPSED TIME National Element NA

Definition

The amount of time for the procedure to be performed.

Field Values

Relevant data for the field, auto-calculated based on start and end times


Calculated in minutes


1 Patient care record

2 Operative report




Data Format: [time] single entry Pick list: No Min Value: N A Max Value: NA Accepts Null Value: Yes


2017 206

HOSPITAL PROCEDURE INFORMATION SCC County Element PR_08 State Element HP_01 ICD-10 HOSPITAL PROCEDURES National Element HP_01

Definition

Operative and selected non-operative procedures conducted during hospital stay. Operative

and selected non-operative procedures are those that were essential to the diagnosis,

stabilization, or treatment of the patient’s specific injuries or complications. The list of

procedures below should be used as a guide to non-operative procedures that should be

provided to NTDB.

Field Values

Major and minor procedure ICD-10-CM procedure codes.

The maximum number of procedures that may be reported for a patient is 200.


The null value “Not Applicable” is used if the patient did not have procedures.

Include only procedures performed at your institution.

Capture all procedures performed in the operating room.

Capture all procedures in the ED, ICU, ward, or radiology department that were essential to the diagnosis, stabilization, or treatment of the patient’s specific injuries or their complications.

Procedures with an asterisk have the potential to be performed multiple times during one episode of hospitalization. In this case, capture only the first event. If there is no asterisk, capture each event even if there is more than one.

Note that the hospital may capture additional procedures.

DIAGNOSTIC AND THERAPEUTIC IMAGING MUSCULOSKELETAL

Computerized tomographic Head * Soft tissue/bony debridements *

Computerized tomographic Chest * Closed reduction of fractures

Computerized tomographic Abdomen * Skeletal and halo traction

Computerized tomographic Pelvis * Fasciotomy

Diagnostic ultrasound (includes FAST) *

Doppler ultrasound of extremities * TRANSFUSION

Angiography The following blood products should be captured over first 24 hours after hospital arrival:

Angioembolization Transfusion of red cells *

REBOA (ICD10: 04L03DZ) Transfusion of platelets *

Transfusion of plasma *

IVC filter RESPIRATORY

Insertion of endotracheal tube * (exclude intubations performed in the OR)

Continuous mechanical ventilation *

CARDIOVASCULAR Chest tube *

Bronchoscopy *

Tracheostomy


2017 207

Open cardiac massage GASTROINTESTINAL

CPR Endoscopy (includes gastroscopy, sigmoidoscopy, colonoscopy)

Gastrostomy/jejunostomy (percutaneous or endoscopic)

CNS Percutaneous (endoscopic) gastrojejunoscopy

Insertion of ICP monitor *

Ventriculostomy *

Cerebral oxygen monitoring *

GENITOURINARY

Ureteric catheterization (i.e. Ureteric stent)

Suprapubic cystostomy


1. Radiology readings / Lab results 2. ED Records 3. ICU Records 4. Operative Reports 5. Billing Sheet / Medical Records Coding Summary Sheet 6. Hospital Discharge Summary



0559 1 Invalid value (ICD-10 CM only)

0560 1 Procedures with the same code cannot have the same Hospital Procedure Start Date and Time


0562 4 Field should not be Not Applicable unless patient had no procedures performed


Data Format: [numeric] single entry Pick list: Yes

Min Value: N A Max Value: NA Accepts Null Value: Yes


2017 208

HOSPITAL PROCEDURE INFORMATION SCC County Element PR_09 State Element NA ICD-10 HOSPITAL PROCEDURES TEXT National Element NA

Definition

The text version of the ICD-10 Code used for procedures.

Field Values

Relevant for the code selected



4. Radiology readings/Lab results

5. ED records

6. Operative Records




Data Format: [alpha] single entry Pick list: Yes

Min Value: N A Max Value: NA Accepts Null Value: Yes


2017 209

HOSPITAL PROCEDURE INFORMATION SCC County Element PR_10 State Element NA MD CODE National Element NA

Definition

Code number assigned to surgeon that performed the surgical procedure in the operating

room.

Field Values



Pick list specific to each center


1. OR Records




Data Format: [alpha] multiple entries Picklist: Yes, facility-modifiable Min Value: N/A Max Value: N/A Accepts Null Value: Yes


2017 210

HOSPITAL PROCEDURE INFORMATION SCC County Element PR_11 State Element NA MD LONG NAME National Element NA

Definition

Name of surgeon that performed the surgical procedure in the operating room.

Field Values

• Relevant value for data element Additional Information

Pick list specific to each center


1. OR Records




Data Format: [alpha] multiple entries Picklist: Yes, facility-modifiable Min Value: N/A Max Value: N/A Accepts Null Value: Yes


2017 211

HOSPITAL PROCEDURE INFORMATION SCC County Element PR _12 State Element NA SERVICE National Element NA

Definition

Patient assigned to a specific area for care.

Field Values

21 Anesthesiology

13 Burn

29 Cardiology

04 Cardiothoracic


26 DDS

05 ENT/OHNS


34 GI

06 General Surgery




27 Neurology

03 Neurosurgery



08 Ophthalmology


02 Orthopedics

30 Pain

23 Pathology



17 Pediatrics

11 Plastic Surgery

24 Psychiatry

25 Radiology

14 Rehab

33 Renal

19 Replant Service

01 Trauma

16 Urology



Data source hierarchy

OR records




Data Format: [numeric] multiple entries Picklist: Yes, facility-modifiable Min Value: N/A Max Value: N/A Accepts Null Value: Yes


2017 212

HOSPITAL PROCEDURE INFORMATION SCC County Element PR _13 State Element NA

ELAPSED TIME TO PROCEDURE National Element NA

Definition

The amount of time from admission to trauma center to time procedure is started.

Field Values

Auto-calculated in minutes



1 ED record

2 Operating room record




Data Format: [numeric] auto-calculated Picklist: No Min Value: N/A Max Value: N/A Accepts Null Value: Yes


2017 213

HOSPITAL PROCEDURE INFORMATION SCC County Element PR_14 State Element NA BLOOD PRODUCTS National Element NA

Definition Total amount of all packed red blood cells, received by the patient during hospital stay – including ED total, given in the first 4 hours.

Field Values



Amount administered in 0-4 hours.


1. ED Records

2. Blood Bank Records




Data Format: [numeric] Picklist: No Min Value: N/A Max Value: N/A Accepts Null Value: Yes


2017 214


FIRST OR TEMPERATURE National Element NA

Definition

Initial temperature of patient on OR admission if within 24 hours.

Field Values

Relevant to data collected


Document in Celsius.


Operating room record




Data Format: [alpha] Picklist: Yes Min Value: N/A Max Value: N/A Accepts Null Value: Yes


2017 215


TEMPERATURE UNITS National Element NA

Definition

The temperature taken in Celsius.

Field Values

C (Celsius)



OR Record




Data Format: [Alpha] Picklist: Yes Min Value: N/A Max Value: N/A Accepts Null Value: Yes


2017 216


TIME TO FIRST OR VISIT National Element NA

Definition

This is the auto-calculated time from patient arrival to OR.

Field Values

Auto calculated



OR record




Data Format: [NUMERIC] auto-calculation Picklist: No Min Value: N/A Max Value: N/A Accepts Null Value: Yes


2017 217

HOSPITAL PROCEDURE INFORMATION SCC County Element PR_18 State Element NA STUDY National Element NA

Definition

Type of radiological study performed, if applicable. Field Values ANGIO Interventional Angiogram (Catheter or Formal Angiogram)

CONTRAST Contrast Studies

CT ANGIO Computerized Tomography Scan includes CT Angio

ULTRASOUND All ultrasound except FAST exam

MRI Magnetic Resonance Imaging (includes MRI Angio)

PLAIN FILMS Plain Film

RADIONUCLEOTIDE SCANS Radionucleotide Scans

FAST Focused Assessment Sonography for Trauma


• CTs and MRIs may or may not include contrast. Should contrast be utilized (CT Angiogram / MRI Angiogram), it is administered via a peripheral vein and is therefore considered non-invasive. CT angiograms and MRI angiograms should simply be coded as a CT Scan.

• Interventional Angiogram (88.49) (Catheter Angiogram, Formal Angiogram)

involves interventional radiology and is considered invasive. A catheter is inserted

into an artery or vein through a small incision, and is moved directly into the artery

being studied. X-ray images can be obtained while contrast is delivered directly

into the artery being studied and allows for embolization (39.79) if needed.

• Include plain films if positive and not identified on CT Scan. Include all CT Scans,

regardless of findings.



2. ED Records






2017 218

HOSPITAL PROCEDURE INFORMATION SCC County Element PR_19 State Element NA BODY PART National Element NA

Definition

Body region studied, if applicable. Field Values

Abdomen Abdomen

C/Spine Cervical Spine

Chest Chest

Extremity Extremity

Face Face

Head Head

Heart Heart

Lower Lower Extremity

L/Spine Lumbar spine

Pelvis Pelvis

T/Spine Thoracic Spine

Upper Upper Extremity

Other Other


• Orbital X-Ray with contrast

• Nasal Sinus X-Ray with contrast

• Kidney X-Ray with contrast (Intravenous pyelogram) Data Source Hierarchy


2. ED Records




Data Format: [ALPHA, 1] Pick list: Yes Min Value: NA Max Value: NA Accepts Null Value: No


2017 219

HOSPITAL PROCEDURE INFORMATION SCC County Element PR_20 State Element NA RESULTS National Element NA

Definition

Results of x-ray, CAT scan, and/or ultrasound studies, if applicable.

Field Values

• NEG Negative

• POS Positive

• INC Inconclusive



2. ED Records






2017 220

CO-MORBIDITIES INFORMATION


2017 221

CO-MORBIDITIES INFORMATION SCC County Element CO_1 State Element DG_01 CO-MORBID CONDITIONS National Element DG_01

Definition

Pre-existing co-morbid factors present before patient arrival at the ED/hospital.

Field Values

02 Alcohol Use Disorder

16 Angina pectoris

35 Bleeding disorder

07 Congestive heart failure

10 Cerebrovascular Accident (CVA)

06 Currently receiving chemotherapy for cancer

36 Congenital anomalies

08 Current smoker

09 Chronic renal failure

13 Advanced directive limiting care

11 Diabetes mellitus

12 Disseminated cancer

15 Functionally dependent health status

20 Hypertension

17 Myocardial infarction (MI)

31 Other

37 Prematurity

38 Chronic Obstructive Pulmonary Disease (COPD)

24 Steroid use

50 Cirrhosis

51 Dementia

52 Mental/Personality Disorder

53 Substance abuse disorder

55 Attention deficit disorder/attention deficit hyperactivity disorder (ADD/ADHD)

56 Anticoagulant Therapy

60 Peripheral Arterial Disease (PAD)


The null value “Not Applicable” is used for patient with no known co-morbid conditions.

For any Co-Morbid Condition to be valid, there must be a diagnosis noted in the patient

medical record that meets the definition noted in Appendix 3: Glossary of Terms.



2017 222






Data Format: [NUMERIC] Picklist: Yes Min Value: N/A Max Value: N/A Accepts Null Value: Yes


2017 223

Diagnosis Information


2017 224

DIAGNOSIS INFORMATION SCC County Element D_02 State Element DG_02 ICD-10 INJURY DIAGNOSES National Element DG_02

Definition Diagnoses related to all identified injuries. Field Values

Injury diagnoses as defined by ICD-10-CM code range: S00-S99, T07, T14, T20-T28 and T30-T32.

The maximum number of diagnoses that may be reported for an individual patient is 50. Additional Information

ICD-10-CM codes pertaining to other medical conditions (e.g., CVA, MI, co-morbidities, etc.) may also be included in this field.

Used to auto-generate additional calculated fields: Abbreviated Injury Scale (six body regions) and Injury Severity Score.

Data Source Hierarchy 1. Hospital Discharge Summary 2. Billing Sheet / Medical Records Coding Summary Sheet 3. ER and ICU Records



0578 1 Invalid value (ICD-10 CM only)


0580 2 At least one diagnosis must be provided and meet inclusion criteria. (ICD-10 CM only)



0583 2 At least one diagnosis must be provided and meet inclusion criteria. (ICD-10 CA only)

Data Format: [NUMERIC] auto-calculation Picklist: No Min Value: N/A Max Value: N/A Accepts Null Value: Yes


2017 225

DIAGNOSIS INFORMATION SCC County Element D_03 State Element IS_01 AIS PREDOT CODE National Element IS_01

Definition

The Abbreviated Injury Scale (AIS) pre-dot codes that reflect the patient’s injuries.

Field Values

The pre-dot code is the 6 digits preceding the decimal point in an associated AIS code


The Abbreviated Injury Scale (AIS) is an anatomical scoring system used to estimate

survivability by ranking the severity of the injury according to an ordinal scale.


Hospital medical records

PCR




0585 3 AIS codes are not valid AIS 05, Update 08 codes



Data Format: [NUMERIC] Picklist: Yes Min Value: N/A Max Value: N/A Accepts Null Value: Yes


2017 226

DIAGNOSIS INFORMATION SCC County Element D_04 State Element IS_02 AIS SEVERITY National Element IS_02

Definition

The Abbreviated Injury Scale (AIS) severity codes that reflect the patient’s injuries.

Field Values

1 Minor Injury 5 Critical Injury

2 Moderate Injury 6 Maximum Injury, Virtually Unsurvivable

3 Serious Injury 7 Not possible to assign

4 Severe Injury


The field value (7) “Not Possible to Assign” would be chosen if it is not possible to assign

a severity to an injury.


Hospital medical records

PCR






Data Format: [NUMERIC] Picklist: Yes

Min Value: 1 Max Value: 9 Accepts Null Value: Yes


2017 227

DIAGNOSIS INFORMATION SCC County Element D_05 State Element NA ISS LOCAL National Element NA

Definition

The Injury Severity Score (ISS) that reflects the patient’s injuries.

Field Values

Relevant ISS value for the constellation of injuries


Auto calculated using AIS Severity/ISS Body Region fields.

To calculate an ISS, take the highest AIS severity code in each of the three most severely

injured ISS body regions, square each AIS code, and add the three squared numbers for an

ISS. ISS scores are calculated using the following six body regions:

o Head or Neck

o Face

o Chest

o Abdominal or Pelvic Contents

o Extremities or Pelvic Girdle

o External




0591 1 Locally calculated ISS is outside the valid range of 1 - 75

0592 3 Value should be the sum of three squares


Data Format: [NUMERIC] Picklist: Yes Min Value: 1 Max Value: 75 Accepts Null Value: Yes


2017 228

DIAGNOSIS INFORMATION SCC County Element D_06 State Element NA ISS BODY REGION National Element NA

Definition

The Injury Severity Score (ISS) body region codes that reflect the patient’s injuries.

Field Values

1 Head or neck 4 Abdominal or pelvic contents

2 Face 5 Extremities or pelvic girdle

3 Chest 6 External


This variable is considered optional and is not required as part of the NTDS dataset.

Head or neck injuries include injury to the brain or cervical spine, skull or cervical spine

fractures.

Facial injuries include those involving mouth, ears, nose and facial bones.

Chest injuries include all lesions to internal organs. Chest injuries also include those to

the diaphragm, rib cage and thoracic spine.

Abdominal or pelvic contents injuries include all lesions to internal organs. Lumbar spine

lesions are included in the abdominal or pelvic region.

Injuries to the extremities or to the pelvic or shoulder girdle include sprains, fractures,

dislocations, and amputations, except for the spinal column, skull and rib cage.

External injuries include lacerations, contusions, abrasions, and burns, independent of

their location on the body surface.


Hospital Patient record




0595 2 Field cannot be blank when AIS PreDot Code is not: (1) blank, (2) Not Applicable, or (3) Not Known/Not Recorded

Data Format: [NUMERIC] Picklist: Yes Min Value: 1 Max Value: 6 Accepts Null Value: Yes


2017 229

DIAGNOSIS INFORMATION SCC County Element D_07 State Element NA

INJURY ICD-10 DX TEXT National Element NA

Definition

All the following data fields are auto calculated/filled according to data entered in other fields.

Field Values

GCS Qualifier

RR Qualifier

Head/Neck

Face

Chest

Abd/Pelvic

Extremities

External

ISS

New ISS

Probability of survival






Data Format: [NUMERIC,Auto calculated] Picklist: NA Min Value: N/A Max Value: N/A Accepts Null Value: No


2017 230

DISCHARGE INFORMATION


2017 231

DISCHARGE INFORMATION SCC County Element DS_01 State Element O_03 HOSPITAL DISCHARGE DATE National Element O_03

Definition

The date the order was written for the patient to be discharged from the hospital.

Field Values



Used to auto-generate an additional calculated field: Total Length of Hospital Stay

(elapsed time from ED/hospital arrival to hospital discharge).

The null value “Not Applicable” is used if ED Discharge Disposition = 5

(Deceased/expired).

The null value “Not Applicable” is used if ED Discharge Disposition = 4, 6, 9, 10, or 11.

If Hospital Discharge Disposition is 5 Deceased/Expired, then Hospital Discharge Date is

the date of death as indicated on the patient’s death certificate.








0600 3 Hospital Discharge Date is earlier than EMS Dispatch Date

0601 3 Hospital Discharge Date is earlier than EMS Unit Arrival on Scene Date

0602 3 Hospital Discharge Date is earlier than EMS Unit Scene Departure Date

0603 2 Hospital Discharge Date is earlier than ED/Hospital Arrival Date

0604 2 Hospital Discharge Date is earlier than ED Discharge Date

0605 3 Hospital Discharge Date is earlier than Date of Birth

0606 3 Hospital Discharge Date minus Injury Incident Date is greater than 365 days, please verify this is correct

0607 3 Hospital Discharge Date minus ED/Hospital Arrival Date is greater than 365 days, please verify this is correct

0608 2 Field must be Not Applicable when ED Discharge Disposition = 4,6,9,10, or 11

0609 2 Field must be Not Applicable when ED Discharge Disposition = 5 (Died)

Data Format: [DATE] Picklist: NA Min Value: NA Max Value: NA Accepts Null Value: No


2017 232

DISCHARGE INFORMATION SCC County Element DS_02 State Element O_04 HOSPITAL DISCHARGE TIME National Element O_04

Definition

The time the order was written for the patient to be discharged from the hospital.

Field Values



Used to auto-generate an additional calculated field: Total Length of Hospital Stay

(elapsed time from ED/hospital arrival to hospital discharge).

The null value “Not Applicable” is used if ED Discharge Disposition = 5

(Deceased/expired).

The null value “Not Applicable” is used if ED Discharge Disposition = 4, 6, 9, 10, or 11.

If Hospital Discharge Disposition is 5 Deceased/Expired, then Hospital Discharge Time

is the time of death as indicated on the patient’s death certificate.


Patient medical record






0613 4 Hospital Discharge Time is earlier than EMS Dispatch Time

0614 4 Hospital Discharge Time is earlier than EMS Unit Arrival on Scene Time

0615 4 Hospital Discharge Time is earlier than EMS Unit Scene Departure Time

0616 4 Hospital Discharge Time is earlier than ED/Hospital Arrival Time

0617 4 Hospital Discharge Time is earlier than ED Discharge Time



Data Format: [TIME] Picklist: NA Min Value: NA Max Value: NA Accepts Null Value: No


2017 233

DISCHARGE INFORMATION SCC County Element DS_03 State Element NA LENGTH OF STAY National Element NA

Definition

The length of stay in the hospital in minutes.

Field Values

Field is auto-calculated






Data Format: [auto-calculated] Picklist: NA Min Value: NA Max Value: NA Accepts Null Value: No


2017 234

DISCHARGE INFORMATION SCC County Element DS_04 State Element O_05 HOSPITAL DISCHARGE DISPOSITION National Element O_05

Definition

The disposition of the patient when discharged from the hospital.

Field Values

05 Deceased/expired

06 Discharged to home or self-care (routine discharge)

10 Discharged/Transferred to court/law enforcement

04 Left against medical advice or discontinued care

11 Discharged/Transferred to a psychiatric hospital or psychiatric distinct part unit of a hospital

01 Discharged/Transferred to a short-term general hospital for inpatient care

03 Discharged/Transferred to home under care of organized home health service

08 Discharged/Transferred to hospice care

09 Discharged/Transferred to inpatient rehab or designated unit

07 Discharged/Transferred to Skilled Nursing Facility (SNF)

02 Discharged/Transferred to an Intermediate Care Facility (ICF)

12 Discharged/Transferred to Long Term Care Hospital (LTCH)

13 Discharged/Transferred to another type of institution not defined elsewhere


Field value = 6, “home” refers to the patient’s current place of residence (e.g., prison,

Child Protective Services etc.)

Field values based upon UB – 04 disposition coding.

Disposition to any other non-medical facility should be coded as 6.

Disposition to any other medical facility should be coded as 13.











2017 235

0626 2 Field cannot be Not Known/Not Recorded when Hospital Arrival Date and Hospital Discharge Date are not: (1) blank, (2) Not Applicable, or (3) Not Known/Not Recorded

Data Format: [Numeric] Picklist: Yes Min Value: NA Max Value: NA Accepts Null Value: No


2017 236

DISCHARGE INFORMATION SCC County Element DS_05 State Element NA LIVE/DIE National Element NA

Definition

Documents whether or not the patient survived the incident.

Field Values

L = Lived

D = Died



Patient medical Record




Data Format: [Alpha] Picklist: Yes Min Value: NA Max Value: NA Accepts Null Value: No


2017 237

DISCHARGE INFORMATION SCC County Element DS_06 State Element NA REASON FOR TRANSFER National Element NA

Definition

The code for the reason for transferring a patient to another acute care facility.

Field Values

09 Financial

08 Higher level of care

12 Other

10 Patient choice

11 Repatriation other County

06 Spec Care Burns

01 Spec Care Neuro Head

03 Spec Care Orthopedics

04 Spec Care Pediatrics

07 Spec Care Re-implant

02 Spec Care Spinal

05 Spec Care Vascular

15 Spec Care Max Face









2017 238

DISCHARGE INFORMATION SCC County Element DS_07 State Element NA TRANSFER TO HOSPITAL National Element NA

Definition

The code for the hospital to which the patient was transferred.

Field Values

27 Arroyo - Grande Hospital

28 Coalinga Hospital

26 Community Hosp of Monterey Peninsula

5 Community Hospital of Los Gatos

30 Doctors Hospital - San Pablo

29 Doctors Hospital - Modesto

6 Dominican Hospital

7 Eden Medical Center

8 El Camino Hospital

31 Emmanuel

2 Good Samaritan

10 Hazel Hawkins

32 Kaiser - Fremont

33 Kaiser - Hayward

34 Kaiser - NFS

35 Kaiser - Redwood City

17 Kaiser - San Jose Med Ctr

16 Kaiser - Santa Clara

9 Kaiser - South SF

36 Kaweah Delta

37 Kern Medical

38 Lodi Medical

39 Madera Community

40 Marian Medical Center

41 Marin General

12 Mee Memorial

42 Memorial Los Banos

43 Memorial Med. Ctr. - Modesto

44 Mercy Med - Merced

45 Mercy Med - Redding

46 Mills Peninsula

25 Natividad Medical Center

47 North Bay Med Ctr

13 O'Connor Hospital

99 Other

14 Palo Alto Veteran's

48 Queen of the Valley

49 RK Davies


19 Salinas Valley Memorial

68 San Francisco General Hospital

50 San Joaquin General

51 San Mateo Med. Ctr (CHOPE)

52 Santa Cruz County Community Hosp.

53 Santa Rosa Memorial

20 Sequoia Hospital

21 Seton Hospital

54 Sierra View

55 Sonora Regional Medical Center

56 St. Agnes Hospital

57 St. Joseph Hospital

18 St. Louise Hospital

58 St. Rose Hospital

11 Stanford Children's Health

22 Stanford Health Care

59 Sutter - Delta

60 Sutter - Solano

61 Sutter - Tracy

62 Tulare District Hospital

63 Tuolumne General

64 Twin Cities Hospital

65 Vaca Valley Hospital

23 Valley Medical Center

66 Washington Hospital

67 Washoe/Renown Hospital

24 Watsonville Community


2017 239









2017 240

DISCHARGE INFORMATION SCC County Element DS_08 State Element NA TRANSFER OUT FOR HIGHER LEVEL OF CARE National Element NA

Definition

The interfacility transfer of a trauma patient from a trauma center to another trauma center for

higher level (greater level of trauma resources) of trauma care.

Field Values

Y = Yes

N = No







Data Format: [Alpha ] Picklist: Yes

Min Value: NA Max Value: NA Accepts Null Value: No


2017 241

DISCHARGE INFORMATION SCC County Element DS_09 State Element NA REPATRIATION National Element NA

Definition

Was HMO patient transferred (repatriated) to a managed care facility.

Field Values

Y = Yes

N = No


Patients who are from adjacent counties may be repatriated to their home county when

stable



Associated Edit Checks:





2017 242

DISCHARGE INFORMATION SCC County Element DS_10 State Element F_01 PRIMARY METHOD OF PAYMENT National Element F_01

Definition

Primary source of payment for hospital care.

Field Values

01 Medicaid

05 Medicare

06 Other Government

02 Not Billed (for any reason)

04 Private/Commercial Insurance

03 Self-Pay

09 Kaiser

13 Other


No Fault Automobile, Workers Compensation, and Blue Cross/Blue Shield should be

captured as Private/Commercial Insurance.








Data Format: [Numeric] Picklist: Yes



2017 243

DISCHARGE INFORMATION SCC County Element DS_11 State Element NA TOTAL HOSPITAL CHARGES National Element NA

Definition

The final billed amount charged for this admission, aggregate amount expressed in whole dollar

figures.

Field Values

Relevant to the data required.



Patient medical records

Patient billing records







2017 244

DEATH INFORMATION


2017 245

DEATH INFORMATION SCC County Element DE_01 State Element NA

DEATH LOCATION National Element NA

Definition

The code for the location in the hospital where the patient died, if applicable.

Field Values

19 Angio

13 Burn unit

20 CT

17 ED

11 ICU

15 Interventional radiology

21 MRI

03 Med/Surg

22 NICU

06 OB Obs

01 OR

02 Obs Unit

08 PICU

07 Pediatric Floor

30 Pediatric OR

16 Radiology

14 Rehab

23 SICU


09 Step Down

10 TCU

25 Telemetry

18 Trauma Room



Patient Care Record






2017 246

DEATH INFORMATION SCC County Element DE_02 State Element NA ORGAN/TISSUE DONATION REFERRAL National Element NA

Definition

This field asks if there was a referral made.

Field Values

Y- Yes

N- No










2017 247

DEATH INFORMATION SCC County Element DE_03 State Element NA FAMILY APPROACHED National Element NA

Definition

Describes whether or not the family was approached about organ/tissue donation.

Field Values

Y - Yes

N - No









2017 248

DEATH INFORMATION SCC County Element DE_04 State Element NA ORGAN/TISSUE DONATION CONSENT National Element NA

Definition

Describes whether or not consent was obtained.

Field Values

Y – Yes

N – No









2017 249

DEATH INFORMATION SCC County Element DE_05 State Element NA AUTOPSY National Element NA

Definition

Defines whether or not an autopsy was done.

Field Values

Y- Yes

N- No

P - Pending



Patient medical Record




Data Format: [Alpha] Picklist: Yes



2017 250

DEATH INFORMATION SCC County Element DE_06 State Element NA

AUTOPSY TYPE National Element NA

Definition

The code for the type of autopsy done.

Field Values

01 Full

02 Partial

03 External Exam









2017 251

DEATH INFORMATION SCC County Element DE_07 State Element NA AUTOPSY ID National Element NA

Definition

Coroner ID # found on autopsy report.

Field Values







Data Format: [Numeric] Picklist: No Min Value: NA Max Value: NA Accepts Null Value: No


2017 252

DEATH INFORMATION SCC County Element DE_08 State Element NA ORGAN/TISSUES PROCURED National Element NA

Definition

The code for the organ/tissue donated.

Field Values

Bone

Corneas

Lung

Heart

Kidneys

Liver

Pancreas

Tissue









2017 253

SURGEON SPECIFIC REPORTING

**The field(s) in this section are optional**


2017 254

SURGEON SPECIFIC REPORTING SCC County Element SSR_01 State Element SSR_01 NATIONAL PROVIDER IDENTIFIER (NPI) National Element SSR_01

Definition

The National Provider Identifier (NPI) of the admitting surgeon.

Field Values



This variable is considered optional and is not required as part of the NTDS dataset.

Must be stored as a 10 digit numerical value.






Data Format: [Numeric] Picklist: No Min Value: NA Max Value: NA Accepts Null Value: No


2017 255

QUALITY ASSURANCE INFORMATION


2017 256

Santa Clara County – Trauma

Performance Improvement Indicators for 2016

N=NTDB S=State (CEMSIS) C=County

1000 PREHOSPITAL AIRWAY

1007-C Inappropriate Airway Management

Management of the airway that is less than optimal as evidenced by low oxygen saturation,

ineffective respiratory rate or low GCS without definitive airway or OPA/NPA and BVM. Includes

esophageal intubation verified by physical examination or roentgenogram and mainstem

intubation resulting in definitive placement of the tube in either the right or left mainstem

bronchus. Includes the inability to establish airway via intubation either by nasal or oral routes in a

patient who would not require RSI.

1009-C Other Airway

Any pre-hospital airway complication not previously listed.

2000 PREHOSPITAL - MISCELLANEOUS

2080-C Triage

Injured patients not identified as trauma patients in the pre-hospital phase of care who require

inter-facility transfer to a trauma center or a trauma team activation/trauma surgeon evaluation

following a trauma center ED evaluation.

2099-C Other Pre-hospital Miscellaneous

Any pre-hospital miscellaneous complication not previously listed. This includes all vital signs

missing on the PCR pertinent to RTS score.

2500 HOSPITAL – AIRWAY

2501-C Esophageal Intubation

Any attempt at endotracheal intubation that resulted in placement of the endotracheal tube in the

esophagus verified by physical examination, visualization or x-ray.

2502-C Extubation, Unintentional

Inadvertent, accidental, unplanned removal of endotracheal tube or

tracheostomy/cricothyroidotomy tube, including tube placement discovered to be in the pharynx

after the tube had been verified to be in the trachea.


2017 257

2503-C Mainstem Intubation

Any endotracheal intubation procedure resulting in definitive placement of the tube in either the

right or left mainstem bronchus.

2504-N Unplanned Intubation

Patient requires placement of an endotracheal tube and mechanical or assisted ventilation because

of the onset of respiratory or cardiac failure manifested by severe respiratory distress, hypoxia,

hypercarbia, or respiratory acidosis. In patients who were intubated in the field or Emergency

Department, or those intubated for surgery, unplanned intubation occurs if they require re-

intubation > 24 hours after extubation.

(NTDB 2017 – A3.10)

2599-C Other Hospital Airway

Any other airway complication occurring in the hospital setting not previously listed.

3000 HOSPITAL - PULMONARY

3002-N Acute Respiratory Distress Syndrome (ARDS) (Consistent with the 2012 New Berlin Definition.)

Timing: Within 1 week of know clinical insult or new or worsening respiratory symptoms.

Chest imaging: Bilateral opacities – not fully explained by effusions, lobar/lung collage, or nodules.

Origin of edema: Respiratory failure not fully explained by cardiac failure of fluid overload. Need objective assessment (echocardiography) to exclude hydrostatic edema if no risk factor present

Oxygenation: 200<PaO2/FIO2≤300 (at a minimum) With PEEP or CPAP ≥ 5cm H2Oc

(NTDB 2017 – A3.5)

3014-N Pulmonary Embolism

A lodging of a blood clot in a pulmonary artery with subsequent obstruction of blood supply to the

lung parenchyma. The blood clots usually originate from the deep leg veins or the pelvic venous

system. Consider the condition present if the patient has a V-Q scan interpreted as high probability

of pulmonary embolism or a positive pulmonary arteriogram or positive CT angiogram and/or

diagnosis of PE is documented in the patient’s medical record. Must have occurred during the

patient's initial stay at your hospital. Sub-Segmental PE’s are not included.

(NTDB 2016 – A3.12)

3098-N Ventilator Associated Pneumonia (Consistent with the January 2015 CDC Defined VAP)

A pneumonia where the patient is on mechanical ventilation for >2 days on the date of event, with

the day of ventilator placement being Day 1,


2017 258

AND

The ventilator was in place on the date of event or the day before. If the patient is admitted or

transferred into a facility or a ventilator the day of admission is considered Day 1.

See VAP algorithm in 2016 NTDB Data Dictionary (A3.11-3.12)

(NTDB 2017 – 3.14-3.17)

3099-C Other Pulmonary

Any other pulmonary complication not previously listed.

3500 HOSPITAL - CARDIOVASCULAR

3502-N Cardiac Arrest with CPR

Cardiac arrest is the sudden cessation of cardiac activity after hospital arrival. The patient becomes

unresponsive with no normal breathing and no signs of circulation. If corrective measures are not

taken rapidly, this condition progresses to sudden death. Cardiac arrest must be documented in

the patient’s medical record, and must have occurred during the patient’s initial stay at your

hospital.

EXCLUDE patients who are receiving CPR on arrival to your hospital.

INCLUDE patients who have had an episode of cardiac arrest evaluated by hospital personnel, and

received compressions or defibrillation or cardioversion or cardiac pacing to restore circulation.

(NTDB 2017 – A3.6)

3505-N Myocardial Infarction

An acute myocardial infarction must be noted with documentation of any of the following:

Documentation of ECG changes indicative of acute MI (one or more of the following three):

1. ST elevation >1 mm in two or more contiguous leads

2. New left bundle branch block

3. New q-wave in two or more contiguous leads

OR

New elevation in troponin greater than three times upper level of the reference range in the

setting of suspected myocardial ischemia


2017 259

OR

Physician diagnosis of myocardial infarction

Must have occurred during the patient’s initial stay at your hospital.

NTDB 2017 – A3.10)

3599-C Other Cardiovascular

Other cardiovascular complication not previously listed.

4000 HOSPITAL – GASTROINTESTINAL (GI)

4099-C Other GI

Other GI complication not previously listed.

4500 HOSPITAL – HEPATIC, PANCREATIC, BILIARY, SPLENIC

4599-C Other Hepatic, Pancreatic, Biliary, Splenic

5000 HOSPITAL - HEMATOLOGIC

5006-C Massive Transfusion

Greater than 6 units of PRBC are within the first 24 hours of admission. Massive Transfusion

Protocol was implemented.

5099-C Other Hematologic

5500 HOSPITAL – INFECTION (Non-pulmonary, Non-orthopedic)

5504-N Central line-associated bloodstream infection (Consistent with the January 2016 CDC defined

CLABSI) A laboratory-confirmed bloodstream infection (LCBI) where the central line (CL) or

umbilical catheter (UC) was in place for >2 calendar days on the date of event, with day of device

placement being Day 1,

AND

The line was also in place on the date of event or the day before. If a CL or UC was in place for >2

calendar days and then removed, the date of the LCBI must be the day of discontinuation or the

next day to be a CLABSI. If the patient is admitted or transferred into a facility with an implanted

central line (port) in place, and that is the patient’s only central line, day of first access in an

inpatient location is considered Day 1. “Access” is defined as line placement, infusion or

withdrawal through the line. Such lines continue to be eligible for CLABSI once they are accessed

until they are either discontinued or the day after patient discharge (as per the Transfer Rule). Note

that the “de-access” of a port does not result in the patient’s removal from CLABSI surveillance.


2017 260

January 2016 CDC Criterion LCBI 1:

Patient has a recognized pathogen cultured from one or more blood specimens by a culture or

non-culture based microbiologic testing method which is performed for purposes of clinical

diagnosis or treatment (e.g., not Active Surveillance Culture/Testing (ASC/AST).

AND

Organism(s) identified in blood is not related to an infection at another site.

OR


Patient has at least one of the following signs or symptoms: fever (>38◦C), chills, or hypotension

AND


AND

the same common commensal (i.e., diphtheroids [Corynebacterium spp. Not C. diphtheria], Bacillus

spp. [not B. anthracis], Propionibacterium spp., coagulase-negative staphylococci [including S.

epidermidis], viridans group streptococci, Aerococcus spp., and Micrococcus spp.) is identified from

two or more blood specimens drawn on separate occasions, by a culture or non-culture based

microbiologic testing method which is performed for purposes of clinical diagnosis or treatment

(e.g., not Active Surveillance Culture/Testing (ACS/AST). Criterion elements must occur within the

Infection Window Period, the 7-day time period which includes the collection date of the positive

blood, the 3 calendar days before and the 3 calendar days after.

OR


Patient ≤1 year of age has a least one of the following signs or symptoms: fever (>38◦C),

hypothermia (<36◦ C), apnea, or bradycardia

AND


AND

i.e., diphtheroids [Corynebacterium spp. Not C. diphtheria], Bacillus spp. [not B. anthracis],

Propionibacterium spp., coagulase-negative staphylococci [including S. epidermidis], viridans group

streptococci, Aerococcus spp., and Micrococcus spp.) is identified from two or more blood

specimens drawn on separate occasions, by a culture or non-culture based microbiologic testing

method which is performed for purposes of clinical diagnosis or treatment (e.g., not Active


2017 261

Surveillance Culture/Testing (ACS/AST). Criterion elements must occur within the Infection Window

Period, the 7-day time period which includes the collection date of the positive blood, the 3

calendar days before and the 3 calendar days after.

(NTDB 2017– A3.7-3.8)

5511-N Superficial Incisional Surgical Site Infection (SSI) (Consistent with the January 2016 CDC Defined

SSI.)

Must meet the following criteria:

Infection occurs within 30 days after any NHSN operative procedure (where day 1 = the procedure

date)

AND

involves only skin and subcutaneous tissue of the incision

AND

patient has at least one of the following:

a. purulent drainage from the superficial incision.

b. organisms identified from an aseptically-obtained specimen from the superficial

incision or subcutaneous tissue by a culture or non-culture based microbiologic testing

method which his performed for purposes of clinical diagnosis or treatment (e.g., not

Active Surveillance Culture/Testing (ASC/AST).

c. superficial incision that is deliberately opened by a surgeon, attending physician** or

other designee and culture or non-culture based testing is not performed.

AND

patient has at least one of the following signs or symptoms: pain or tenderness; localized

swelling; erythema; or heat. A culture or non-culture based test that has a negative

finding does not meet this criterion.

d. diagnosis of a superficial incisional SSI by the surgeon or attending physician** or other

designee.

COMMENTS: There are two specific types of superficial incisional SSIs:

1. Superficial Incisional Primary (SIP) – a superficial incisional SSI that is identified in the

primary incision in a patient that has had an operation with one or more incisions (e.g., C-

section incision or chest incision for CBGB)

2. Superficial Incisional Secondary (SIS) – a superficial incisional SSI that is identified in the

secondary incision in a patient that has had an operation with more than one incision

(e.g., donor site incision for CBGB)

A diagnosis of SSI must be documented in the patient’s medical record, and must have

occurred during the patient’s initial stay at your hospital.

(NTDB 2017 – A3.13)

5512-N Deep Surgical Site Infection (SSI)


2017 262

Must meet the following criteria: Infection occurs within 30 or 90 days after the NHSN operative procedure (where day 1 = the procedure date) According to list in Table 2 AND involves deep soft tissues of the incision (e.g., fascial and muscle layers) AND patient has at least one of the following: a. purulent drainage from the deep incision. b. a deep incision that spontaneously dehisces, or is deliberately opened or aspirated by a surgeon, attending physician** or other designee and organism is identified by a culture or non-culture based microbiologic testing method which is performed for purposes of clinical diagnosis or treatment (e.g., not Active Surveillance Culture/Testing (ASC/AST) or culture or non-culture based microbiologic testing method is not performed AND patient has at least one of the following signs or symptoms: fever (>38°C); localized pain or tenderness. A culture or non-culture based test that has a negative finding does not meet this criterion. c. an abscess or other evidence of infection involving the deep incision that is detected on gross anatomical or histopathologic exam, or imaging test COMMENTS: There are two specific types of deep incisional SSIs: 1. Deep Incisional Primary (DIP) – a deep incisional SSI that is identified in a primary incision in a patient that has had an operation with one or more incisions (e.g., C-section incision or chest incision for CBGB) 2. Deep Incisional Secondary (DIS) – a deep incisional SSI that is identified in the secondary incision in a patient that has had an operation with more than one incision (e.g., donor site incision for CBGB)

Table 2. Surveillance Period for Deep Incisional or Organ/Space SSI Following Selected NHSN

Operative Procedure Categories. Day 1 = the date of the procedure.

30-day Surveillance

Code Operative Procedure Code Operative Procedure

AAA Abdominal LAM Laminectomy

AMP Limb amputation LTP Liver transplant

APPY Appendix surgery NECK Neck surgery

AVSD Shunt for dialysis NEPH Kidney surgery

BILI Bile duct, liver or pancreatic surgery OVRY Ovarian surgery

CEA Carotid endarterectomy PRST Prostate surgery

CHOL Gallbladder surgery REC Rectal surgery

COLO Colon surgery SB Small bowel surgery

CSEC Cesarean surgery SPLE Spleen surgery

GAST Gastric surgery THOR Thoracic surgery

HTP Heart transplant THUR Thyroid and/or parathyroid surgery

HYST Abdominal hysterectomy VHYS Vaginal hysterectomy

KTP Kidney transplant XLAP Exploratory Laparotomy

90-day Surveillance

BRST Breast surgery

CARD Cardiac surgery

CBGB Coronary artery bypass graft with both chest and donor site incisions

CBGC Coronary artery bypass graft with chest incision only


2017 263

CRAN Craniotomy

FUSN Spinal fusion

FX Open reduction of fraction

HER Herniorrhaphy

HPRO Hip prosthesis

KPRO Knee prosthesis

PACE Pacemaker surgery

PVBY Peripheral vascular bypass surgery

VSHN Ventricular shunt

A diagnosis of SSI must be documented in the patient’s medical record, and must have occurred during the patient’s initial stay at your hospital. (NTDB 2017 – A3.8)

5513-N Organ / Space Surgical Site Infection

Must meet the following criteria: Infection occurs within 30 or 90 days after the NHSN operative procedure (where day 1 = the procedure date) according to the list in Table 2 AND infection involves any part of the body deeper than the fascial/muscle layers, that is opened or manipulated during the operative procedure AND patient has at least one of the following: a. purulent drainage from a drain that is placed into the organ/space (e.g., closed suction drainage system, open drain, T-tube drain, CT guided drainage) b. organisms are identified from an aseptically-obtained fluid or tissue in the organ/space by a culture or non-culture based microbiologic testing method which is performed for purposes of clinical diagnosis or treatment (e.g., not Active Surveillance Culture/Testing (ASC/AST). c. an abscess or other evidence of infection involving the organ/space that is detected on gross anatomical or histopathologic exam, or imaging test AND meets at least one criterion for a specific organ/space infection site listed in Table 3. These criteria are found in the Surveillance Definitions for Specific Types of Infections chapter. Table 2. Surveillance Period for Deep Incisional or Organ/Space SSI Following Selected NHSN Operative Procedure Categories. Day 1 = the date of the procedure.

30-day Surveillance


AAA Abdominal LAM Laminectomy

AMP Limb amputation LTP Liver transplant

APPY Appendix surgery NECK Neck surgery

AVSD Shunt for dialysis NEPH Kidney surgery

BILI Bile duct, liver or pancreatic surgery OVRY Ovarian surgery

CEA Carotid endarterectomy PRST Prostate surgery

CHOL Gallbladder surgery REC Rectal surgery

COLO Colon surgery SB Small bowel surgery

CSEC Cesarean surgery SPLE Spleen surgery

GAST Gastric surgery THOR Thoracic surgery

HTP Heart transplant THUR Thyroid and/or parathyroid surgery

HYST Abdominal hysterectomy VHYS Vaginal hysterectomy


2017 264

KTP Kidney transplant XLAP Exploratory Laparotomy

90-day Surveillance

BRST Breast surgery

CARD Cardiac surgery

CBGB Coronary artery bypass graft with both chest and donor site incisions

CBGC Coronary artery bypass graft with chest incision only

CRAN Craniotomy

FUSN Spinal fusion

FX Open reduction of fraction

HER Herniorrhaphy

HPRO Hip prosthesis

KPRO Knee prosthesis

PACE Pacemaker surgery

PVBY Peripheral vascular bypass surgery

VSHN Ventricular shunt

Table 3. Specific Sites of an Organ/Space SSI.


BONE Osteomyelitis LUNG Other infections of the respiratory tract

BRST Breast abscess mastitis MED Mediastinitis

CARD Myocarditis or pericarditis MEN Meningitis or ventriculitis

DISC Disc space ORAL Oral cavity (mouth, tongue, or gums)

EAR Ear, mastoid OREP Other infections of the male or female reproductive tract

EMET Endometritis PJI Periprosthetic Joint Infection

ENDO Endocarditis SA Spinal abscess without meningitis

EYE Eye, other than conjunctivitis SINU Sinusitis

GIT GI tract UR Upper respiratory tract

HEP Hepatitis USI Urinary System Infection

IAB Intraabdominal, not specified VASC Arterial or venous infection

IC Intracranial, brain abscess or dura

VCUF Vaginal cuff

JNT Joint or bursa

A diagnosis of SSI must be documented in the patient’s medical record, and must have

occurred during the patient’s initial stay at your hospital.

(NTDB 2017 – A3.10)

5514-N Severe Sepsis

Severe sepsis: sepsis plus organ dysfunction, hypotension (low blood pressure), or hypoperfusion

(insufficient blood flow) to 1 or more organs.

Septic shock: sepsis with persisting arterial hypotension despite adequate fluid resuscitation.

A diagnosis of Sepsis must be documented in the patient’s medical record, and must have occurred

during the patient’s initial stay at your hospital.


2017 265

(NTDB 2017 - A3.12)

5599-C Other Infection

Other infectious complication not previously listed. Include epididynitis and retroperitoneal

infection. Do not report FUO or conjunctivitis.

6000 HOSPITAL – RENAL / GENITOURINARY (GU)

6001-N Acute Kidney Injury (AKI) (Consistent with the March 2012 Kidney Disease Improving Global

Outcome (KDIGO) Guideline.) Acute Kidney Injury, AKI (stage 3), is an abrupt decrease in kidney

function that occurred during the patient’s initial stay at your hospital.

KDIGO (Stage 3) Table:

Serum creatinine (SCr) 3 times baseline

OR

Increase in SCr to > 4.0 mg/dl (> 353.6 µmol/l)

OR

Initiation of renal replacement therapy OR, in patients < 18 years, decrease in eGFR to < 35 ml/min

per 1.73 m2

OR

Urine output <0.3 ml/kg/h for > 24 hours

OR

Anuria for > 12 hours

A diagnosis of AKI must be documented in the patient’s medical record. If the patient or family

refuses treatment (e.g., dialysis,) the condition is still considered to be present if a combination of

oliguria and creatinine are present.

EXCLUDE patients with renal failure that were requiring chronic renal replacement therapy such as

periodic peritoneal dialysis, hemodialysis, or hemodiafiltration prior to injury.

(NTDB 2017 – A3.5)

6010-N Catheter- associated Urinary Tract Infection (CAUTI) (Consistent with the January 2016 CDC

defined CAUTI.) A UTI where an indwelling urinary catheter was in place for > 2 calendar days on

the date of event, with day of device placement being Day 1,

AND


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An indwelling urinary catheter was in place on the date of event or the day before. If an indwelling

urinary catheter was in place for >2 calendar days and then removed, the date of event for the UTI

must be in the day of discontinuation or the next day for the UTI to be catheter-associated.

January 2016 CDC CAUTI Criterion SUTI 1a:

Patient must meet 1, 2, and 3 below:

1. Patient had an indwelling urinary catheter in place for the entire day on the date of event and such catheter had been in place for >2 calendar days, on the date (day of device in placement = Day 1) AND was either:

Present for any portion of the calendar day on the date of event, OR

Removed the day before the date of event

2. Patient has at least one the following signs or symptoms:

Fever (>38◦C)

Suprapubic tenderness with no other recognized cause

Costovertebral angle pain or tenderness with no other recognized cause

3. Patient has a urine culture with no more than two species of organisms, at least one of which is a bacteria >105 CFU/ml.

January 2016 CDC CAUTI Criterion SUTI 2:

Patient must meet 1.2, and 3 below:

1. Patient is ≤ 1 year of age

2. Patient has at least one of the following signs or symptoms:

Fever (>38.0◦C)

Hypotherimia (<36.0◦C)

Apnea with no other recognized cause

Bradycardia with no other recognized cause

Lethargy with no other recognized cause

Vomiting with no other recognized cause

Suprapubic tenderness with no other recognized cause

3. Patient has a urine culture with no more than two species of organisms, at least one of which is bacteria of ≥ 105 CFU/ml.

A diagnosis of UTI must be documented in the patient’s medical record, and must have occurred during the patient’s initial stay at your hospital. (NTDB – 2017 A3.6-3.7)

6099-C Other Renal/GU

Other renal or GU complication not previously listed.

6500 HOSPITAL – MUSCULOSKELETAL / INTEGUMENTARY


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6501-N Extremity Compartment Syndrome

A condition not present at admission in which there is documentation of tense muscular

compartments of an extremity through clinical assessment or direct measurement of intra-

compartmental pressure requiring fasciotomy. Compartment syndromes usually involved the leg

but can also occur in the forearm, arm, thigh, and shoulder. A diagnosis of Extremity Compartment

Syndrome must be documented in the patient’s medical record, and must have occurred during

the patient’s initial stay at your hospital. Only record as a complication if it is originally missed,

leading to late recognition, a need for late intervention and has threatened limb viability.

(NTDB 2017 – A3.10)

6508-N Osteomyelitis(Consistent with the January 2016 CDC definition of Bone and Joint infection.)

Osteomyelitis must meet at least one of the following criteria:

1. Patient has organisms identified from bone by culture or non-culture based microbiologic testing method which is performed for purposes of clinical diagnosis and treatment (e.g., not Active Surveillance Culture/Testing (ASC/AST).

2. Patient has evidence of osteomyelitis on gross anatomic or histopathologic exam. 3. Patient has at least two of the following localized signs or symptoms: fever (>38.0°C),

swelling*, pain or tenderness*, heat*, or drainage*

And least one of the following:

a. organisms identified from blood by culture or non-culture based microbiologic testing method which is performed for purposes of clinical diagnosis and treatment (e.g., not Active Surveillance Culture/Testing (ASC/AST) in a patient with imaging test evidence suggestive of infection (e.g., x-ray, CT scan, MRI, radiolabel scan [gallium, technetium, etc.]), which if equivocal is supported by clinical correlation (i.e., physician documentation of antimicrobial treatment for osteomyelitis). b. imaging test evidence suggestive of infection (e.g., x-ray, CT scan, MRI, radiolabel scan [gallium, technetium, etc.]), which if equivocal is supported by clinical correlation (i.e., physician documentation of antimicrobial treatment for osteomyelitis).

*With no other recognized cause A diagnosis of Osteomyelitis must be documented in the patient’s medical record, and must have occurred during the patient’s initial stay at your hospital.

(NTDB 2017 – A3.11-3.12)

6511-N Pressure Ulcer:(Consistent with the National Pressure Ulcer Advisory Panel (NPUAP) 2014.)

A localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of

pressure, or pressure in combination with shear. A number of contributing or confounding factors

are also associated with pressure ulcers; the significance of these factors is yet to be elucidated.

Equivalent to NPUAP Stages II-IV, Unstageable/Unclassified, and Suspected Deep Tissue Injury.

Documentation of Pressure Ulcer must be in the patient’s medical record, and must have occurred

during the patient’s initial stay at your hospital.


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(NTDB 2017 – A3.12)

6599-C Other Musculoskeletal / Integumentary

Other musculoskeletal or integumentary complication not previously listed.

7000 HOSPITAL - NEUROLOGIC

7012 Alcohol Withdrawal Syndrome (Consistent with the 2016 World Health Organization (WHO)

definition of Alcohol Withdrawal Syndrome.)

Characterized by tremor, sweating, anxiety, agitation, depression, nausea, and malaise. It occurs 6-

48 hours after cessation of alcohol consumption, and when uncomplicated, abates after 2-5 days. It

may be complicated by grand mal seizures and may progress to delirium (known as delirium

tremens). Must have occurred during the patient's initial stay at your hospital, and documentation

of alcohol withdrawal must be in the patient's medical record. (NTDB 2017 – A3.6)

7011-N Stroke / CVA

A focal or global neurological deficit of rapid onset and NOT present on admission. The patient

must have at least one of the following symptoms:

Change in level of consciousness

Hemiplegia

Hemiparesis

Numbness or sensory loss affecting on side of the body

Dysphasia or aphasia

Hemianopia (decreased vision or blindness in half of the visual field)

Amaurosis fugax (loss of vision in one eye that is not permanent)

Other neurological signs or symptoms consistent with stroke

AND:

Duration of neurological deficit ≥ 24 hours OR:

Duration of deficit < 24 h, if neuroimaging (MR, CT, or cerebral angiography) documents a new hemorrhage or infarct consistent with stroke, or therapeutic intervention(s) were performed for stroke, or the neurological deficit results in death

AND:

No other readily identifiable non-stroke cause, e.g., progression of existing traumatic brain injury, seizure, tumor, metabolic or pharmacologic etiologies, is identified

AND:

Diagnosis is confirmed by neurology or neurosurgical specialist or neuroimaging procedure (MR, CT, angiography,) or lumbar puncture (CSF demonstrating intracranial hemorrhage that was not present on admission).


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Although the neurologic deficit must not present on admission, risk factors predisposing to stroke

(e.g., blunt cerebrovascular injury, dysrhythmia) may be present on admission. A diagnosis of

Stroke/CVA must be documented in the patient’s medical record, and must have occurred during

the patient’s initial stay at your hospital.

(NTDB 2017 - A3.13)

7099-C Other Neurologic

Other neurologic complication not previously listed.

7500 HOSPTIAL - VASCULAR

7502-N Deep Vein Thrombosis – DVT

The formation, development, or existence of a blood clot or thrombus within the vascular system,

which may be coupled with inflammation. The patient must be treated with anticoagulation

therapy and/or placement of a vena cava filter or clipping of the vena cava. A diagnosis of DVT

must be documented in the patient’s medical record. This diagnosis may be confirmed by a

venogram, ultrasound, or CT, and must have occurred during the patient’s initial stay at your

hospital.

Venous thrombosis proximal to or involving the popliteal vein. Confirmed by autopsy, venogram,

duplex scan or non-invasive vascular evaluation.(RMC definition) Document affected vein in memo

field on Lancet complication sheet.

(NTDB 2017 – A3.9)

7599-C Other Vascular

Other vascular complication not previously listed.

8500 HOSPITAL - OTHER (This section is not downloaded to County Central Registry)

8506-N Unplanned Return to OR

Unplanned return to the operating room after initial operation management for a similar or related

previous procedure.

(NTDB 2016 – A3.10)

8507-C Unexpected Readmission

Readmission to the hospital within 30 days of discharge for complications related to prior

admission.

8515-C Referring Facility Complication


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Any complication that occurred at the referring facility for trauma patients transferred in that

resulted in morbidity. Do not include referring facility complications as pre-hospital complications

or complications occurring during the pre-hospital phase of care. The Trauma Medical Director

identifies the complication.

8575-N Unplanned Admission to ICU

INCLUDE:

Patients readmitted to the ICU after initial transfer to the floor.

Patients with an unplanned return to the ICU after initial ICU discharge. EXCLUDE:

Patients in which ICU care was required for postoperative care of a planned surgical procedure.

(NTDB 2016 – A3.10)

8599-C Other Miscellaneous

Any other miscellaneous hospital complication not previously listed.

9000 HOSPITAL – PROVIDER ERRORS / DELAYS (This section is not downloaded to County)

9001-C Delay in Disposition

A disposition from the ED/Trauma Room to ICU for patients with an ISS of > 15, is not accomplished

within 2 hours of admitting orders due to delay in availability of resources.

9002-C Delay in Trauma Team Activation

Trauma team should have been activated sooner, as identified by a negative impact on patient

care. If this is an unacceptable decision it should be noted under “error in judgment”.

9004-C Delay in Physician / Surgeon Response

Trauma Surgeon does not respond within 15 minutes of patient arrival for Tier 1 activation or

within 30 minutes of patient arrival for Tier 2 activation. Or a subspecialist (neuro, ortho, etc.)

does not arrive in an appropriate time frame.

9005-C Delay in Obtaining Subspecialty Consultation

When consultation is not ordered by ED physician/Trauma surgeon/Resident and is found to

impact patient care.

9006-C Delay in Diagnosis

Trauma related diagnosis made greater than 24 hours after admission.


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9007-C Error in Diagnosis

Trauma injury was missed due to misinterpretation or inadequacy of physical examination or

diagnostic procedures(s).

9008-C Error in Judgment

Therapeutic or diagnostic decision made contrary to available data or acceptable standard practice

that affects patient care.

9009-C Error in Technique

Technical error occurring during the performance of a diagnostic or therapeutic procedure that

affects patient care.

9011-C Delay in Obtaining Trauma Consult

Delayed identification of a major trauma victim as one who requires a trauma surgeon consult. An

unacceptable decision implies an “error in judgment.”

9014-C Definitive Orthopedic Surgical Treatment > 24 hours

Greater than 24 hours to definitive surgical care for long bone fractures.

9016-C Delay to OR-Laparotomy

Patients with abdominal injuries and sustained hypotension (SBP < 90 mm Hg) after initial fluid

resuscitation, who do not undergo laparotomy within 1 hour of arrival in the ED.

9017-C Delay to OR – Craniotomy

Patient with epidural or subdural brain hematoma receiving craniotomy > 4 hrs after arrival at

emergency department, excluding those performed for ICP monitoring.

9018-C Delay to OR Washout – Open Long Bone Fracture

Interval of > 24 hours between arrival and the initiation of debridement in the OR of an open long

bone fracture, excluding a low velocity gunshot wound. (humerus and femur)

9019-C Lack of Definitive Airway with GCS < 9

A comatose patient (GCS < 9) leaving ED before definitive airway is established.

9020-C Initial OR > 24 hours

Initial abdominal, thoracic, vascular, or cranial surgery performed > 24 hours after arrival. This

does not include patients already identified in 9016, 9017, and 9018.

9083-C Radiology Issue (delay, error, mis-read)


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This indicator can include but is not limited to a delay in reporting radiographic results, an error in

interpretation or an over-read film or scan. Note the specific issue in memo field on complication

screen in Lancet.

9084-C Delay in Treatment

Delay in providing definitive therapy; may be related to delay in diagnosis or missed diagnosis,

error in diagnosis, or failure to respond to results of physical examination or diagnostic procedure.

9087-C Error in Treatment

Treatment provided or administered is contrary to available information or acceptable standards.

9099-C Other-Hospital Provider Error / Delay

Any other provider related error or delay not indicated by any other complication code.


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Appendix 3: Glossary of Terms

CO-MORBID CONDITIONS

Advanced directive limiting care: The patient had a written request limiting life sustaining

therapy, or similar advanced directive, present prior to arrival at your center.

Alcohol use disorder (Consistent with APA DSM 5): Diagnosis of alcohol use disorder

documented in the patient’s medical record, present prior to injury.

Attention deficit disorder/Attention deficit hyperactivity disorder (ADD/ADHD): A disorder

involving inattention, hyperactivity, or impulsivity requiring medication for treatment, present

prior to ED/Hospital arrival. A diagnosis of ADD/ADHD must be documented in the patient’s

medical record.

Bleeding disorder: A group of conditions that result when the blood cannot clot properly,

present prior to injury. A Bleeding Disorder diagnosis must be documented in the patient’s

medical record (e.g. Hemophilia, von Willenbrand Disease, Factor V Leiden.)

Cerebrovascular accident (CVA): A history prior to injury of a cerebrovascular accident

(embolic, thrombotic, or hemorrhagic) with persistent residual motor sensory or cognitive

dysfunction (e.g., hemiplegia, hemiparesis, aphasia, sensory deficit, impaired memory.) A

diagnosis of CVA must be documented in the patient’s medical record.

Chronic Obstructive Pulmonary Disease (COPD): Lung ailment that is characterized by a

persistent blockage of airflow from the lungs, present prior to injury. It is not one single disease

but an umbrella term used to describe chronic lung diseases that cause limitations in lung

airflow. The more familiar terms “chronic bronchitis” and “emphysema” are no longer used, but

are now included within the COPD diagnosis and result in any one or more of the following:

• Functional disability from COPD (e.g., dyspnea, inability to perform activities of daily

living [ADLs].)

• Hospitalization in the past for treatment of COPD.

• Requires chronic bronchodialator therapy with oral or inhaled agents.

• A Forced Expiratory Volume in 1 second (FEV1) of < 75% or predicted on pulmonary function

testing. A diagnosis of COPD must be documented in the patient’s medical record. Do not

include patients whose only pulmonary disease is acute asthma, and/or diffuse interstitial

fibrosis or sarcoidosis.

Chronic renal failure: Chronic renal failure prior to injury that was requiring periodic peritoneal

dialysis, hemodialysis, hemofiltration, or hemodiafiltration, present prior to injury. A diagnosis of

Chronic Renal Failure must be documented in the patient’s medical record.

Cirrhosis: Documentation in the medical record of cirrhosis, which might also be referred to as

end stage liver disease, present prior to injury. If there is documentation of prior or present

esophageal or gastric varices, portal hypertension, previous hepatic encephalopathy, or ascites

with notation of liver disease, then cirrhosis should be considered present. A diagnosis of


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Cirrhosis, or documentation of Cirrhosis by diagnostic imaging studies or a

laparotomy/laparoscopy, must be in the patient’s medical record.

Congenital Anomalies: Documentation of a cardiac, pulmonary, body wall, CNS/spinal, GI,

renal, orthopaedic, or metabolic congenital anomaly, present prior to injury. A diagnosis of a

Congenital Anomaly must be documented in the patient’s medical record.

Congestive Heart Failure (CHF): The inability of the heart to pump a sufficient quantity of

blood to meet the metabolic needs of the body or can do so only at an increased ventricular

filling pressure, present prior to injury. To be included, this condition must be noted in the

medical record as CHF, congestive heart failure, or pulmonary edema with onset of increasing

symptoms within 30 days prior to injury. Common manifestations are:

• Abnormal limitation in exercise tolerance due to dyspnea or fatigue A3.2

• Orthopnea (dyspnea on lying supine)

• Paroxysmal nocturnal dyspnea (awakening from sleep with dyspnea)

• Increased jugular venous pressure

• Pulmonary rales on physical examination

• Cardiomegaly

• Pulmonary vascular engorgement

Current Smoker: A patient who reports smoking cigarettes every day or some days within the

last 12 months, prior to injury. Excludes patients who smoke cigars or pipes or use smokeless

tobacco (chewing tobacco or snuff.)

Currently receiving chemotherapy for cancer: A patient who is currently receiving any

chemotherapy treatment for cancer, prior to injury. Chemotherapy may include, but is not

restricted to, oral and parenteral treatment with chemotherapeutic agents for malignancies such

as colon, breast, lung, head and neck, and gastrointestinal solid tumors as well as lymphatic

and hematopoietic malignancies such as lymphoma, leukemia, and multiple myeloma.

Dementia: Documentation in the patient’s medical record of dementia including senile or

vascular dementia (e.g., Alzheimer’s) present prior to injury .

Diabetes mellitus: Diabetes mellitus that requires exogenous parenteral insulin or an oral

hypoglycemic agent, present prior to injury. A diagnosis of Diabetes Mellitus must be

documented in the patient’s medical record.

Disseminated cancer: Patients who have cancer that has spread to one site or more sites in

addition to the primary site AND in whom the presence of multiple metastases indicates the

cancer is widespread, fulminant, or near terminal, present prior to injury. Other terms describing

disseminated cancer include: “diffuse,” “widely metastatic,” “widespread,” or “carcinomatosis.”

Common sites of metastases include major organs, (e.g., brain, lung, liver, meninges, abdomen,

peritoneum, pleura, and/or bone). A diagnosis of Cancer that has spread to one or more sites

must be documented in the patient’s medical record.


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Functionally Dependent health status: Pre-injury functional status may be represented by the

ability of the patient to complete age appropriate activities of daily living (ADL) including:

bathing, feeding, dressing, toileting, and walking. This item is marked YES if the patient, prior to

injury, and as a result of cognitive or physical limitations relating to a pre-existing medical

condition, was partially dependent or completely dependent upon equipment, devices or another

person to complete some or all activities of daily living.

Hypertension: History of persistent elevated blood pressure requiring medical therapy, present

prior to injury. A diagnosis of Hypertension must be documented in the patient’s medical record.

Mental/Personality Disorder: Documentation of the presence of pre-injury depressive

disorder, bipolar disorder, schizophrenia, borderline or antisocial personality disorder, and/or

adjustment disorder/post-traumatic stress disorder. A diagnosis of Mental/Personality Disorder

must be documented in the patient’s medical record.

Peripheral Arterial Disease (PAD): The narrowing or blockage of the vessels that carry blood

from the heart to the legs, present prior to injury. It is primarily caused by the buildup of fatty

plaque in the arteries, which is called atherosclerosis. PAD can occur in any blood vessel, but it

is more common in the legs than the arms. A diagnosis of PAD must be documented in the

patient’s medical record.

Prematurity: Premature birth is defined as infants delivered before 37 weeks from the first day

of the last menstrual period, and a history of bronchopulmonary dysplasia, or ventilator support

for greater than 7 days after birth. A diagnosis of Prematurity, or delivery before 37 weeks

gestation, must be documented in the patient’s medical record.

Steroid use: Patients that require the regular administration of oral or parenteral corticosteroid

medications within 30 days prior to injury for a chronic medical condition. Examples of oral or

parenteral corticosteroid medications are: prednisone and dexamethasone. Examples of chronic

medical conditions are: COPD, asthma, rheumatologic disease, rheumatoid arthritis, and

inflammatory bowel disease. Do not include topical corticosteroids applied to the skin or

corticosteroids administered by inhalation or rectally.

Substance Abuse Disorder: Documentation of Substance Abuse Disorder documented in the

patient medical record, present prior to injury. A diagnosis of Substance Abuse Disorder must

be documented in the patient’s medical record.


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PATIENT’S OCCUPATIONAL INDUSTRY: The occupational history associated with the

patient’s work environment.

Field Value Definitions:

Finance and Insurance - The Finance and Insurance sector comprises establishments

primarily engaged in financial transactions (transactions involving the creation, liquidation, or

change in ownership of financial assets) and/or in facilitating financial transactions. Three

principal types of activities are identified:

1. Raising funds by taking deposits and/or issuing securities and, in the process,

incurring liabilities.

2. Pooling of risk by underwriting insurance and annuities.

3. Providing specialized services facilitating or supporting financial intermediation,

insurance, and employee benefit programs.

Real Estate - Industries in the Real Estate subsector group establishments that are primarily

engaged in renting or leasing real estate to others; managing real estate for others; selling,

buying, or renting real estate for others; and providing other real estate related services, such as

appraisal services.

Manufacturing - The Manufacturing sector comprises establishments engaged in the

mechanical, physical, or chemical transformation of materials, substances, or components into

new products. Establishments in the Manufacturing sector are often described as plants,

factories, or mills and characteristically use power-driven machines and materials-handling

equipment. However, establishments that make new products by hand, such as bakeries, candy

stores, and custom tailors, may also be included in this sector.

Retail Trade - The Retail Trade sector comprises establishments engaged in retailing

merchandise, generally without transformation, and rendering services incidental to the sale of

merchandise. The retailing process is the final step in the distribution of merchandise; retailers

are, therefore, organized to sell merchandise in small quantities to the general public. This

sector comprises two main types of retailers:

1. Store retailers operate fixed point-of-sale locations, located and designed to attract a

high volume of walk-in customers.

2. Non-store retailers, like store retailers, are organized to serve the general public, but

their retailing methods differ.

Transportation and Public Utilities - The Transportation and Warehousing sector includes

industries providing transportation of passengers and cargo, warehousing and storage for

goods, scenic and sightseeing transportation, and support activities related to modes of

transportation. The Utilities sector comprises establishments engaged in the provision of the

following utility services: electric power, natural gas, steam supply, water supply, and sewage

removal.


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Agriculture, Forestry, Fishing - The Agriculture, Forestry, Fishing and Hunting sector

comprises establishments primarily engaged in growing crops, raising animals, harvesting

timber, and harvesting fish and other animals from a farm, ranch, or their natural habitats. The

establishments in this sector are often described as farms, ranches, dairies, greenhouses,

nurseries, orchards, or hatcheries.

Professional and Business Services - The Professional, Scientific, and Technical Services

sector comprises establishments that specialize in performing professional, scientific, and

technical activities for others. These activities require a high degree of expertise and training.

The establishments in this sector specialize according to expertise and provide these services

to clients in a variety of industries and, in some cases, to households. Activities performed

include: legal advice and representation; accounting, bookkeeping, and payroll services;

architectural, engineering, and specialized design services; computer services; consulting

services; research services; advertising services; photographic services; translation and

interpretation services; veterinary services; and other professional, scientific, and technical

services.

Education and Health Services - The Educational Services sector comprises establishments

that provide instruction and training in a wide variety of subjects. This instruction and training is

provided by specialized establishments, such as schools, colleges, universities, and training

centers. These establishments may be privately owned and operated for profit or not for profit,

or they may be publicly owned and operated. They may also offer food and/or accommodation

services to their students.

The Health Care and Social Assistance sector comprises establishments providing health care

and social assistance for individuals. The sector includes both health care and social assistance

because it is sometimes difficult to distinguish between the boundaries of these two activities.

Construction - The construction sector comprises establishments primarily engaged in the

construction of buildings or engineering projects (e.g., highways and utility systems).

Establishments primarily engaged in the preparation of sites for new construction and

establishments primarily engaged in subdividing land for sale as building sites also are included

in this sector. Construction work done may include new work, additions, alterations, or

maintenance and repairs.

Government – Civil service employees, often called civil servants or public employees, work in

a variety of fields such as teaching, sanitation, health care, management, and administration for

the federal, state, or local government. Legislatures establish basic prerequisites for

employment such as compliance with minimal age and educational requirements and residency

laws.

Natural Resources and Mining - The Mining sector comprises establishments that extract

naturally occurring mineral solids, such as coal and ores; liquid minerals, such as crude

petroleum; and gases, such as natural gas. The term mining is used in the broad sense to

include quarrying, well operations, beneficiating (e.g., crushing, screening, washing, and

flotation), and other preparation customarily performed at the mine site, or as a part of mining

activity.


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Information Services - The Information sector comprises establishments engaged in the

following processes: (a) producing and distributing information and cultural products, (b)

providing the means to transmit or distribute these products as well as data or communications,

and (c) processing data.

Wholesale Trade - The Wholesale Trade sector comprises establishments engaged in

wholesaling merchandise, generally without transformation, and rendering services incidental to

the sale of merchandise. The merchandise described in this sector includes the outputs of

agriculture, mining, manufacturing, and certain information industries, such as publishing.

Leisure and Hospitality - The Arts, Entertainment, and Recreation sector includes a wide

range of establishments that operate facilities or provide services to meet varied cultural,

entertainment, and recreational interests of their patrons. This sector comprises (1)

establishments that are involved in producing, promoting, or participating in live performances,

events, or exhibits intended for public viewing; (2) establishments that preserve and exhibit

objects and sites of historical, cultural, or educational interest; and (3) establishments that

operate facilities or provide services that enable patrons to participate in recreational activities

or pursue amusement, hobby, and leisure-time interests. The Accommodation and Food

Services sector comprises establishments providing customers with lodging and/or preparing

meals, snacks, and beverages for immediate consumption. The sector includes both

accommodation and food services establishments because the two activities are often

combined at the same establishment.

Other Services - The Other Services sector comprises establishments engaged in providing

services not specifically provided for elsewhere in the classification system. Establishments in

this sector are primarily engaged in activities, such as equipment and machinery repairing,

promoting or administering religious activities, grant-making, advocacy, and providing dry-

cleaning and laundry services, personal care services, death care services, pet care services,

photofinishing services, temporary parking services, and dating services.


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PATIENT’S OCCUPATION: The occupation of the patient.

Field Value Definitions:

Business and Financial Operations Occupations:

Buyers and Purchasing Agents

Accountants and Auditors

Claims Adjusters, Appraisers, Examiners, and Investigators

Human Resources Workers

Market Research Analysts and Marketing Specialists

Business Operations Specialists, All Other

Architecture and Engineering Occupations

Landscape Architects

Surveyors, Cartographers, and Photogrammetrists

Agricultural Engineers

Chemical Engineers Civil

Engineers Electrical Engineers

Community and Social Services Occupations

Marriage and Family Therapists

Substance Abuse and Behavioral Disorder Counselors

Healthcare Social Workers

Probation Officers and Correctional Treatment Specialists

Clergy

Education, Training, and Library Occupations

Engineering and Architecture Teachers, Postsecondary Math and

Computer Teachers, Postsecondary

Nursing Instructors and Teachers, Postsecondary

Law, Criminal Justice, and Social Work Teachers, Postsecondary

Preschool and Kindergarten Teachers

Librarians

Healthcare Practitioners and Technical Occupations

Dentists, All Other Specialists Dietitians and Nutritionists Physicians and Surgeons

Nurse

Practitioners Cardiovascular Technologists and Technicians

Emergency Medical Technicians and Paramedics

Protective Service Occupations

Firefighters

Police Officers

Animal Control Workers Security Guards

Lifeguards, Ski Patrol, and Other Recreational Protective Service

Building and Grounds Cleaning and Maintenance


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Building Cleaning Workers

Landscaping and Groundskeeping Workers

Pest Control Workers

Pesticide Handlers, Sprayers, and Applicators, Vegetation

Tree Trimmers and Pruners

Sales and Related Occupations

Advertising Sales Agents

Retail Salespersons

Counter and Rental Clerks

Door-to-Door Sales Workers, News and Street Vendors, and Related Workers

Real Estate Brokers

Farming, Fishing, and Forestry Occupations

Animal Breeders

Fishers and Related Fishing Workers Agricultural Equipment Operators Hunters and

Trappers

Forest and Conservation Workers

Logging Workers

Installation, Maintenance, and Repair Occupations

Electric Motor, Power Tool, and Related Repairers Aircraft Mechanics and Service

Technicians Automotive Glass

Installers and Repairers

Heating, Air Conditioning, and Refrigeration Mechanics and Installers

Maintenance Workers, Machinery Industrial Machinery Installation, Repair, and

Maintenance Workers

Transportation and Material Moving Occupations

Rail Transportation Workers, All Other Subway and Streetcar Operators Packers and

Packagers, Hand Refuse and Recyclable Material Collectors Material Moving

Workers, All Other Driver/Sales Workers

Management Occupations

Public Relations and Fundraising Managers Marketing and Sales Managers

Administrative

Services Managers

Transportation, Storage, and Distribution Managers Food Service Managers

Computer and Mathematical Occupations

Web Developers

Software Developers and Programmers

Database Administrators

Statisticians

Computer Occupations, All Other


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Life, Physical, and Social Science Occupations

Psychologists

Economists Foresters

Zoologists and Wildlife Biologists

Political Scientists

Agricultural and Food Science Technicians

Legal Occupations

Lawyers and Judicial Law Clerks Paralegals and Legal Assistants Court Reporters

Administrative Law Judges, Adjudicators, and Hearing Officers

Arbitrators, Mediators, and Conciliators

Title Examiners, Abstractors, and Searchers

Arts, Design, Entertainment, Sports, and Media

Artists and Related Workers, All Other Athletes, Coaches, Umpires, and Related

Workers

Dancers and Choreographers

Reporters and Correspondents

Interpreters and Translators

Photographers

Healthcare Support Occupations

Nursing, Psychiatric, and Home Health Aides

Physical Therapist Assistants and Aides

Veterinary Assistants and Laboratory Animal Caretakers

Healthcare Support Workers, All Other

Medical Assistants

Food Preparation and Serving Related

Bartenders, Cooks, Institution and Cafeteria

Cooks, Fast Food

Counter Attendants, Cafeteria, Food Concession, and Coffee Shop

Waiters and Waitresses, Dishwashers

Personal Care and Service Occupations

Animal Trainers

Amusement and Recreation Attendants

Barbers, Hairdressers, Hairstylists and Cosmetologists

Baggage Porters, Bellhops, and Concierges

Tour Guides and Escorts

Recreation and Fitness Workers

Office and Administrative Support Occupations

Bill and Account Collectors

Gaming Cage Workers

Payroll and Timekeeping Clerks, Tellers


2017 282

Court, Municipal, and License Clerks

Hotel, Motel, and Resort Desk Clerks

Construction and Extraction Occupations

Brickmasons, Blockmasons, and Stonemasons

Carpet, Floor, and Tile Installers and Finishers

Construction Laborers, Electricians

Pipelayers, Plumbers, Pipefitters, Steamfitters and Roofers

Production Occupations

Electrical, Electronics, and Electromechanical Assemblers

Engine and Other Machine Assemblers

Structural Metal Fabricators and Fitters

Butchers and Meat Cutters

Machine Tool Cutting Setters, Operators, and Tenders, Metal and Plastic

Welding, Soldering, and Brazing Workers

Military Specific Occupations

Air Crew Officers

Armored Assault Vehicle Officers

Artillery and Missile Officers Infantry

Officers

Military Officer Special and Tactical Operations Leaders, All Other


2017 283

Multiple Cause Coding Hierarchy: If two or more events cause separate injuries, an

external cause code should be assigned for each cause. The first-listed external cause

code will be selected in the following order:

1. External cause codes for child and adult abuse take priority over all other

external cause codes

2. External cause codes for terrorism events take priority over all other external

cause codes except child and adult abuse.

3. External cause codes for cataclysmic events take priority over all other

external cause codes except child and adult abuse, and terrorism.

4. External cause codes for transport accidents take priority over all other

external cause codes except cataclysmic events, and child and adult abuse,

and terrorism.

5. The first listed external cause code should correspond to the cause of the

most serious diagnosis due to an assault, accident or self-harm, following the

order of hierarchy listed above.