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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
Santa Clara County Trauma Registry Data Dictionary
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
Santa Clara County Trauma Registry Data Dictionary
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
Santa Clara County Trauma Registry Data Dictionary
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
Santa Clara County Trauma Registry Data Dictionary
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
ADMITTING SERVICE 124
ADMITTING PHYSICIAN 125
Santa Clara County Trauma Registry Data Dictionary
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
ADMITTING PHYSICIAN 135
ADMITTING SERVICE 136
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
Santa Clara County Trauma Registry Data Dictionary
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
Santa Clara County Trauma Registry Data Dictionary
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
Santa Clara County Trauma Registry Data Dictionary
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
Santa Clara County Trauma Registry Data Dictionary
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
Santa Clara County Trauma Registry Data Dictionary
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.
Santa Clara County Trauma Registry Data Dictionary
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)
Santa Clara County Trauma Registry Data Dictionary
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.
Santa Clara County Trauma Registry Data Dictionary
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.
Santa Clara County Trauma Registry Data Dictionary
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).
Santa Clara County Trauma Registry Data Dictionary
2017 16
DEMOGRAPHIC INFORMATION
Santa Clara County Trauma Registry Data Dictionary
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
Additional Information
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
Santa Clara County Trauma Registry Data Dictionary
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
Rule ID Level Message
0003 1 Invalid value
0004 2 Field cannot be blank
Data format: [character,12] auto-populated Pick-list: No Min. Value: N/A Max. Value: N/A Accepts Null Value: No
Santa Clara County Trauma Registry Data Dictionary
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).
Data Source Hierarchy
1. ED Record 2. Billing Sheet/Medical Records Coding Summary Sheet 3. Hospital Discharge Summary
Associated Edit Checks
Rule ID Level Message
0005 1 Date is not valid
0006 1 Date out of range
0007 2 Field cannot be blank
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
Santa Clara County Trauma Registry Data Dictionary
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
Additional Information
User-defined patient visit record identifier
Data Source Hierarchy
1. Hospital Face sheets 2. ED Records 3. Billing sheet/Medical Records Coding summary
Associated Edit Checks
Rule ID Level Message
0019 1 Invalid value
0020 2 Field cannot be blank
Data format: [character, 15] single entry Pick-list: No Min. Value: N/A Max. Value: N/A Accepts Null Value: Yes
Santa Clara County Trauma Registry Data Dictionary
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
Additional Information
User-defined patient visit record identifier.
Data Source Hierarchy
1. Face sheets 2. ED Records 3. Billing sheet/Medical Records Coding summary
Associated Edit Checks
Rule ID Level Message
0021 1 Invalid value
0022 2 Field cannot be blank
Data format: [character, 15] single entry Pick-list: No Min. Value: N/A Max. Value: N/A Accepts Null Value: Yes
Santa Clara County Trauma Registry Data Dictionary
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
Additional Information
Data Source Hierarchy
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
Associated Edit Checks
Rule ID Level Message
0023 1 Invalid value
0024 2 Field cannot be blank
Data format: [character, 15] single entry Pick-list: No Min. Value: N/A Max. Value: N/A Accepts Null Value: Yes
Santa Clara County Trauma Registry Data Dictionary
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
Relevant value for data element
Additional Information
Data Source Hierarchy
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
Associated Edit Checks
Rule ID Level Message
0025 1 Invalid value
0026 2 Field cannot be blank
Data format: [character, 15] single entry Pick-list: No Min. Value: N/A Max. Value: N/A Accepts Null Value: Yes
Santa Clara County Trauma Registry Data Dictionary
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
Relevant value for data element
Additional Information
Data Source Hierarchy
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
Associated Edit Checks
Rule ID Level Message
0027 1 Invalid value
0028 2 Field cannot be blank
Data format: [character, 1] single entry Pick-list: No Min. Value: N/A Max. Value: N/A Accepts Null Value: Yes
Santa Clara County Trauma Registry Data Dictionary
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
Relevant value for data element
Additional Information
Data Source Hierarchy
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
Associated Edit Checks
Rule ID Level Message
0029 1 Invalid value
0030 2 Field cannot be blank
Data format: [character, 15] single entry Pick-list: No Min. Value: N/A Max. Value: N/A Accepts Null Value: Yes
Santa Clara County Trauma Registry Data Dictionary
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
Relevant value for data element
Additional Information
Data Source Hierarchy
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
Associated Edit Checks
Rule ID Level Message
0031 1 Invalid value
0032 2 Field cannot be blank
Data format: [character, 15] single entry Pick-list: No Min. Value: N/A Max. Value: N/A Accepts Null Value: Yes
Santa Clara County Trauma Registry Data Dictionary
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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
Relevant value for data element
Additional Information
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.
Data Source Hierarchy
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
Associated Edit Checks
Rule ID Level Message
0033 1 Invalid value
0034 1 Date out of range
0035 2 Field cannot be blank
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
0044 2 Field cannot be Not Applicable
Data format: [date] single entry Pick-list: No Min. Value: Date minus 120 yrs Max. Value: Current Date Accepts Null: Yes
Santa Clara County Trauma Registry Data Dictionary
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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
Additional Information
Used to calculate patient age in minutes, hours, days, months, or years.
If Date of Birth is “Not Known/Not Recorded”, complete variables: Age and Age Units.
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.
Data Source Hierarchy
1. Face sheet 2. ED Records 3. History and Physical 4. Billing Sheet/Medical Records Coding Summary Sheet 5. EMS Report Form
Associated Edit Checks
Rule ID Level Message
0045 1 Age is outside the valid range of 0 - 120
0046 2 Field cannot be blank
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
Santa Clara County Trauma Registry Data Dictionary
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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)
Additional Information
Normally calculated from date of birth and auto-populated. (SCC)
Used to calculate patient age in minutes, hours, days, months, or years.
If Date of Birth is “Not Known/Not Recorded”, complete variables: Age and Age Units.
If Date of Birth equals ED/Hospital Arrival Date, then the Age and Age Units variables must be completed.
Must also complete variable: Age.
Data Source Hierarchy
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
Associated Edit Checks
Rule ID Level Message
0051 1 Value is not a valid menu option
0052 2 Field cannot be blank
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
Santa Clara County Trauma Registry Data Dictionary
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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)
Additional Information
Patients who have undergone a surgical and/or hormonal sex reassignment should be coded using the current assignment.
Data Source Hierarchy
1. Face Sheet 2. ED Records 3. History and Physical 4. EMS Report Form
Associated Edit Checks
Rule ID Level Message
0055 1 Value is not a valid menu option
0056 2 Field cannot be blank
0057 2 Field cannot be Not Applicable
Data format: [Character, 1] single entry Pick-list: Yes, non-modifiable Min. Value: NA Max. Value: NA Accepts Null: Yes
Santa Clara County Trauma Registry Data Dictionary
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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
Additional Information
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.
Data Source Hierarchy
1. ED Records 2. EMS Report form 3. History and Physical
Associated Edit Checks
Rule ID Level Message
0058 1 Value is not a valid menu option
0059 2 Field cannot be blank
0060 2 Field cannot be Not Applicable (US only)
0061 2 Field must be Not Applicable (non-US)
Data format: [Character, 1] single entry Pick-list: Yes, non-modifiable Min. Value: NA Max. Value: NA Accepts Null: Yes
Santa Clara County Trauma Registry Data Dictionary
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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
Additional Information
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.
Data Source Hierarchy
1. ED Records 2. EMS Report form 3. History and Physical
Associated Edit Checks
Rule ID Level Message
0062 1 Value is not a valid menu option
0063 2 Field cannot be blank
0064 2 Field cannot be Not Applicable (US only)
0065 2 Field must be Not Applicable (non-US)
Data format: [Character, 1] single entry Pick-list: Yes, non-modifiable Min. Value: NA Max. Value: NA Accepts Null: Yes
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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
Additional Information
Document “NA” if SSN is unavailable.
Data Source Hierarchy
1. Face Sheet 2. Billing Sheet 3. EMS Report form
Associated Edit Checks
Rule ID Level Message
0066 1 Invalid value
0067 2 Field cannot be blank
Data format: [Character, 5] single entry Pick-list: No Min Value: 0 Max Value: 9 Accepts Null: Yes
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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
Relevant value for data element
Additional Information
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.
Data Source Hierarchy
1. ED Records 2. EMS Report form
Associated Edit Checks
Rule ID Level Message
0068 1 Invalid value
0069 2 Field cannot be blank
Data format: [Character, 5] single entry Pick-list: No Min. Value: 0 Max. Value: 9 Accepts Null: Yes
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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)
Additional Information
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.
Data Source Hierarchy
1 Face Sheet 2 Billing Sheet/Medical Records Coding Summary Sheet 3 ED Records 3. EMS Report form
Associated Edit Checks
Rule ID Level Message
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
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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)
Additional Information
Only completed when ZIP/Postal code is “Not Recorded/Not Known” and country is US.
Used to calculate FIPS Code.
The null value “Not Applicable” is used if Patient’s Home Zip/Postal Code is reported.
Data Source Hierarchy
4. Face Sheet 5. Billing Sheet/Medical Records Coding Summary Sheet 6. ED Records 4. EMS Report form
Associated Edit Checks
Rule ID Level Message
0073 1 Invalid value (US only)
0074 2 Field cannot be blank (US only)
0075 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
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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)
Additional Information
Only completed when ZIP/Postal code is “Not Recorded/Not Known” and country is US.
Used to calculate FIPS Code.
The null value “Not Applicable” is used if Patient’s Home Zip/Postal Code is reported.
Data Source Hierarchy
1 Face Sheet 2 Billing Sheet/Medical Records Coding Summary Sheet 3 EMS Report form
Associated Edit Checks
Rule ID Level Message
0076 1 Invalid value (US only)
0077 2 Field cannot be blank (US only)
0078 2 Field must be Not Applicable (Non-US)
Data format: [Character,2] single entry Pick-list: Yes Min. Value: 0 Max. Value: 9 Accepts Null: No
Santa Clara County Trauma Registry Data Dictionary
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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)
Additional Information
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.
Data Source Hierarchy
4 Face Sheet 5 Billing Sheet/Medical Records Coding Summary Sheet 6 EMS Report form
Associated Edit Checks
Rule ID Level Message
0079 1 Invalid value
0080 2 Field cannot be blank
0081 2 Field cannot be Not Applicable
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
Santa Clara County Trauma Registry Data Dictionary
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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
Additional Information
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.
The null value “Not Applicable” is used if Patient’s Home Zip/Postal Code is reported.
Data Source Hierarchy
1 Face Sheet 2 History and Physical 3 EMS report form
Associated Edit Checks
Rule ID Level Message
0083 1 Value is not a valid menu option
0084 2 Field cannot be blank
Data format: [Character,1] single entry Pick-list: Yes (non-modifiable) Min. Value: 0 Max. Value: 9 Accepts Null: Yes
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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
Additional Information
Pick list can only be modified by consensus with Trauma Executive Committee.
Data Source Hierarchy
1. Trauma flow sheet 2. Medical Record
Associated Edit Checks
Rule ID Level Message
0085 1 Value is not a valid menu option
0086 2 Field cannot be blank
Data format: [Character, 2] single entry Pick-list: Yes (non-modifiable) Min. Value: 0 Max. Value: 99 Accepts Null: No
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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
Relevant value for data element
Select from the pick list (customizable)
Autofill
Additional Information
Data Source Hierarchy
1. Trauma flow sheet 2. Medical Record
Associated Edit Checks
Rule ID Level Message
0087 1 Invalid value
0088 2 Field cannot be blank
Data format: [Character, 3] single entry Pick-list: Yes (modifiable) Min. Value: 0 Max. Value: 9 Accepts Null: No
Santa Clara County Trauma Registry Data Dictionary
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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
Relevant value for data element
Additional information
The two (2) of three (3) character initials of the person who input the data into this record.
Data Source Hierarchy
1. Trauma registrar
Associated Edit Checks
Rule ID Level Message
0089 1 Invalid value
0090 2 Field cannot be blank
Data format: [Character, 3] single entry Pick-list: No Min. Value: NA Max. Value: NA Accepts Null: No
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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
Relevant value for data element
Additional Information
Data Source Hierarchy
1. Trauma registrar
Associated Edit Checks
Rule ID Level Message
0091 1 Invalid value
0092 2 Field cannot be blank
Data format: [Numeric date, mm/dd/yyyy] single entry Pick-list: No Min. Value: 01/01/2008 Max. Value: current date Accepts Null: No
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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
Relevant value for data element
Additional Information
Auto-populated.
Data Source Hierarchy
Auto-populated by the registry
Associated Edit Checks
Rule ID Level Message
0093 1 Invalid value
0094 2 Field cannot be blank
Data format: [Numeric date, mm/dd/yyyy] single entry Pick-list: No Min. Value: 01/01/2008 Max. Value: current date Accepts Null: No
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PREHOSPITAL INFORMATION
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PREHOSPITAL INFORMATION SCC County Element P_01 State Element NA NAME National Element NA
Definition Patient name auto-populated by the registry.
Field Values
Relevant value for data element
Additional information
Auto-populated.
Data Source Hierarchy
Auto-populated by the registry
Associated Edit Checks
Rule ID Level Message
0095 1 Invalid value
0096 2 Field cannot be blank
Data format: [Text] single entry Pick-list: No Min. Value: 0 Max. Value: 9 Accepts Null: No
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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
Relevant value for data element
Additional Information
Auto-populated from demographics page.
Data Source Hierarchy
Auto-populated by the registry
Associated Edit Checks
Rule ID Level Message
0097 1 Invalid value
0098 2 Field cannot be blank
Data format: [Auto-populated, mm/dd/yyyy] single entry Pick-list: No Min. Value: 01/01/2008 Max. Value: current date Accepts Null: No
Santa Clara County Trauma Registry Data Dictionary
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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
Relevant value for data element
Additional Information
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 Source Hierarchy
Auto-populated by the registry
Associated Edit Checks
Rule ID Level Message
0099 1 Invalid value
0100 2 Field cannot be blank
Data format: [Character,12] single entry Pick-list: No Min. Value: N/A Max. Value: N/A Accepts Null: No
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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
Additional Information
Data Source Hierarchy
Prehospital Care Record (PCR) for ambulance patients
Nursing/triage flow sheet
Associated Edit Checks
Rule ID Level Message
0101 1 Value is not a valid menu option
0102 2 Field cannot be blank
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
0104 2 Field cannot be Not Applicable
Data format: [Numeric character, 1] single entry Pick-list: Yes Min. Value: 0 Max. Value: 7 Accepts Null: Yes
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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
Additional Information
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.
Data Source Hierarchy
Prehospital Care Record (PCR)
Associated Edit Checks
Rule ID Level Message
0105 1 Value is not a valid menu option
0106 2 Field cannot be blank
Data format: [Numeric character, 1] single entry Pick-list: Yes Min. Value: 0 Max. Value: 7 Accepts Null: Yes
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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
Additional Information
Data Source Hierarchy
Prehospital Care Record (PCR)
Associated Edit Checks
Rule ID Level Message
0107 1 Value is not a valid menu option
0108 2 Field cannot be blank
Data format: [Character] single entry Pick-list: Yes Min. Value: N/A Max. Value: N/A Accepts Null: Yes
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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
Additional Information
Data Source Hierarchy
Prehospital Patient Record (PCR)
Associated Edit Checks
Rule ID Level Message
0109 1 Value is not a valid menu option
0110 2 Field cannot be blank
Data format: [Alpha characters [3] single entry Pick-list: Yes Min. Value: 0 Max. Value: 9 Accepts Null: No
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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
Additional Information
Data Source Hierarchy
Patient Medical Record
Associated Edit Checks
Rule ID Level Message
0111 1 Value is not a valid menu option
0112 2 Field cannot be blank
Data format: [Alpha characters [1] single entry Pick-list: Yes Min. Value: 0 Max. Value: 9 Accepts Null: Yes
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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.
Additional Information
Data Source Hierarchy
EMS Patient Care Record
County Communications Computer Aided Dispatch (CAD)
Associated Edit Checks
Rule ID Level Message
0113 1 Invalid value
0114 2 Field cannot be blank
Data format: [Alpha/Numeric] single entry Pick-list: No Min. Value: N/A Max. Value: N/A Accepts Null: Yes
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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
Relevant value for data element
Additional Information
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.
Data Source Hierarchy
EMS PCR
ED Records
Associated Edit Checks
Rule ID Level Message
0115 1 Date is not valid
0116 1 Date out of range
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
0123 2 Field cannot be blank
Data format: [DATE] single entry Pick-list: No Min. Value: 01/01/1979 Max. Value: Current Date Accepts Null: Yes
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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
Relevant value for data element
Additional Information
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.
The null value “Not Applicable” is used for patients who were not transported by EMS.
Data Source Hierarchy
EMS PCR
ED Records
Associated Edit Checks
Rule ID Level Message
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
0131 2 Field cannot be blank
Data format: [TIME] single entry Pick-list: No Min. Value: 0 Max. Value: 2359 Accepts Null: Yes
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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
Relevant value for data element
Additional Information
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).
The null value “Not Applicable” is used for patients who were not transported by EMS.
Data Source Hierarchy
EMS PCR
Associated Edit Checks
Rule ID Level Message
0132 1 Date is not valid
0133 1 Date out of range
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
0141 2 Field cannot be blank
Data format: [DATE] single entry Pick-list: No Min. Value: 01/01/1979 Max. Value: Current Date Accepts Null: Yes
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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
Relevant value for data element
Additional information
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).
The null value “Not Applicable” is used for patients who were not transported by EMS.
Data Source Hierarchy
EMS PCR
Associated Edit Checks
Rule ID Level Message
0142 1 Time is not valid
0143 1 Time out of range
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
0149 2 Field cannot be blank
Data format: [TIME] single entry Pick-list: No Min. Value: 0 Max. Value: 2359 Accepts Null: Yes
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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
Relevant value for data element
Additional Information
Data Source Hierarchy
EMS PCR
Associated Edit Checks
Rule ID Level Message
0150 1 Time is not valid
0151 1 Time out of range
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
0158 2 Field cannot be blank
Data format: [TIME] single entry Pick-list: No Min. Value: 0 Max. Value: 2359 Accepts Null: Yes
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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
Relevant value for data element
Additional Information
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).
The null value “Not Applicable” is used for patients who were not transported by EMS.
Data Source Hierarchy
EMS PCR
Associated Edit Checks
Rule ID Level Message
0159 1 Date is not valid
0160 1 Date out of range
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
0168 2 Field cannot be blank
Data format: [DATE] single entry Pick-list: No Min. Value: 01/01/1979 Max. Value: Current Date Accepts Null: Yes
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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
Relevant value for data element
Additional Information
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).
The null value “Not Applicable” is used for patients who were not transported by EMS.
Data Source Hierarchy
EMS PCR
Associated Edit Checks
Rule ID Level Message
0169 1 Time is not valid
0170 1 Time out of range
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
0176 2 Field cannot be blank
Data format: [TIME] single entry Pick-list: No Min. Value: 0 Max. Value: 2359 Accepts Null: Yes
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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
Relevant value for data element
Additional information
Data Source Hierarchy
EMS PCR
Associated Edit Checks
Rule ID Level Message
0177 1 Time is not valid
0178 1 Time out of range
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
0184 2 Field cannot be blank
Data format: [TIME] single entry Pick-list: No Min. Value: 0 Max. Value: 2359 Accepts Null: Yes
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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
Relevant value for data element
Additional Information
Collected as MM.
Data Source Hierarchy
EMS PCR
Associated Edit Checks
Rule ID Level Message
0185 1 Time is not valid
0186 1 Time out of range
Data format: [TIME] single entry Pick-list: No Min. Value: 0 Max. Value: NA Accepts Null: Yes
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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
Relevant value for data element
Additional Information
Collected as MM.
Data Source Hierarchy
EMS PCR
Associated Edit Checks
Rule ID Level Message
0187 1 Time is not valid
0188 1 Time out of range
Data format: [TIME] single entry Pick-list: No Min. Value: 0 Max. Value: NA Accepts Null: Yes
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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
Relevant value for data element
Additional Information
Collected as MM.
Data Source Hierarchy
EMS PCR
Hospital arrival time
Associated Edit Checks
Rule ID Level Message
0189 1 Time is not valid
0190 1 Time out of range
Data format: [TIME] single entry Pick-list: No Min. Value: 0 Max. Value: NA Accepts Null: Yes
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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*
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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
Additional Information
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.
Data Source Hierarchy
EMS PCR
Associated Edit Checks
Rule ID Level Message
0191 1 Value is not a valid menu option
Data format: [numeric (3)] Pick-list: Yes
Min. Value: 100 Max. Value: 900 Accepts Null: No
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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
Additional Information
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.
Data Source Hierarchy
EMS PCR
Associated Edit Checks
Rule ID Level Message
0192 1 Value is not a valid menu option
0193 2 Field cannot be blank
0194 2 Field cannot be Not Applicable
Data format: [numeric (1)] single entry Pick-list: Yes Min. Value: 1 Max. Value: 2 Accepts Null: No
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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
Rule ID Level Message
0195 1 Value is not a valid menu option
Data format: [numeric (2)] single entry Pick-list: Yes Min. Value: 01 Max. Value: 99 Accepts Null: No
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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
Rule ID Level Message
0196 1 Value is not a valid menu option
0197 2 Field cannot be blank
Data format: [alpha/numeric (3)] single entry Pick-list: Yes Min. Value: NA Max. Value: NA Accepts Null: No
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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
Relevant value for data element
Additional Information
Data Source Hierarchy
EMS PCR
Associated Edit Checks
Rule ID Level Message
0198 1 Date is not valid
0199 1 Date out of range
Data format: [DATE] single entry Pick-list: No Min. Value: 01/01/1979 Max. Value: current date Accepts Null: No
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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
Relevant value for data element
Additional Information
Data Source Hierarchy
EMS PCR
Associated Edit Checks
Rule ID Level Message
0200 1 Time is not valid
0201 1 Time out of range
Data format: [TIME] single entry Pick-list: Yes Min. Value: 00 Max. Value: 2359 Accepts Null: No
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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
Relevant value for data element
Additional Information
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.
Data Source Hierarchy
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)
Associated Edit Checks
Rule ID Level Message
0202 1 Invalid value
0203 2 Field cannot be blank
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
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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
Relevant value for data element
Additional Information
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.
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, respiratory rate from the scene should be
reported. (SCC)
The null value “Not Applicable” is used for patients who arrive by 4. Private/Public
Vehicle/Walk-in.
Data Source Hierarchy
EMS PCR
Associated Edit Checks
Rule ID Level Message
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.
0206 2 Field cannot be blank
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.
Data format: [Numeric] single entry Pick-list: No Min. Value: 00 Max. Value: 50 Accepts Null: No
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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
Additional Information
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.
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, respiratory rate qualifier from the scene should be
reported. (SCC)
Data Source Hierarchy
EMS PCR
Associated Edit Checks
Rule ID Level Message
0208 1 Value is not a valid menu option
0209 2 Field cannot be blank
Data format: [Alpha] single entry Pick-list: Yes Min. Value: NA Max. Value: NA Accepts Null: No
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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
Relevant value for data element
Additional Information
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.
Value should be based upon assessment before administration of supplemental oxygen.
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, oxygen saturation from the scene should be
reported. (SCC)
The null value “Not Applicable” is used for patients who arrive by 4. Private/Public
Vehicle/Walk-in.
Data Source Hierarchy
EMS PCR
Associated Edit Checks
Rule ID Level Message
0210 1 Pulse oximetry is outside the valid range of 0 – 100
0211 2 Field cannot be blank
Data format: [Numeric percentage] single entry Pick-list: No Min. Value: 0 Max. Value: 100 Accepts Null: No
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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
Relevant value for data element
Additional Information
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.
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, 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.
The null value “Not Applicable” is used for patients who arrive by 4. Private/Public
Vehicle/Walk-in.
Data Source Hierarchy
EMS PCR
Associated Edit Checks
Rule ID Level Message
0212 1 Invalid value
0213 2 Field cannot be blank
0214 3 SBP exceeds the max of 300
Data format: [Numeric] single entry Pick-list: No Min. Value: 0 Max. Value: 300 Accepts Null: No
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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
Relevant value for data element
Additional Information
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.
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, diastolic blood pressure from the scene should be
reported. (SCC)
Data Source Hierarchy
EMS PCR
Associated Edit Checks
Rule ID Level Message
0215 1 Invalid value
0216 2 Field cannot be blank
0217 3 DBP exceeds the max of 300
Data format: [Numeric] single entry Pick-list: No Min. Value: 0 Max. Value: 300 Accepts Null: No
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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
Additional Information
Used to calculate Overall GCS – EMS Score.
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.
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.
The null value “Not Applicable” is used for patients who arrive by 4. Private/Public
Vehicle/Walk-in.
Data Source Hierarchy
EMS PCR
Associated Edit Checks
Rule ID Level Message
0218 1 Value is not a valid menu option
0219 2 Field cannot be blank
Data format: [Numeric] single entry Pick-list: Yes, non-modifiable Min. Value: 1 Max. Value: 4 Accepts Null: No
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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
4 Withdrawal from pain
5 Localizing pain
6 Obeys commands
Additional Information
Used to calculate Overall GCS – EMS Score.
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.
If available on inter-facility transports, GCS - Motor 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 withdraws from a painful stimulus,” a Motor GCS of 4 may be recorded, IF there
is no other contradicting documentation.
The null value “Not Applicable” is used for patients who arrive by 4. Private/Public
Vehicle/Walk-in.
Data Source Hierarchy
EMS PCR
Associated Edit Checks
Rule ID Level Message
0220 1 Value is not a valid menu option
0221 2 Field cannot be blank
Data format: [Numeric] single entry Pick-list: Yes, non-modifiable Min. Value: 1 Max. Value: 6 Accepts Null: No
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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
Pediatric (≤ 2 years):
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
Additional Information
Used to calculate Overall GCS – EMS Score.
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.
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.
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.
The null value “Not Applicable” is used for patients who arrive by 4. Private/Public
Vehicle/Walk-in.
Data Source Hierarchy
EMS PCR
Associated Edit Checks
Rule ID Level Message
0222 1 Value is not a valid menu option
0223 2 Field cannot be blank
Data format: [Numeric] single entry Pick-list: Yes, non-modifiable Min. Value: 1 Max. Value: 5 Accepts Null: No
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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
Relevant value for data element
Additional Information
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.
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.
The null value “Not Applicable” is used for patients who arrive by 4. Private/Public
Vehicle/Walk-in.
Data Source Hierarchy
EMS PCR
Associated Edit Checks
Rule ID Level Message
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
0226 2 Field cannot be blank
Data format: [Numeric] single entry Pick-list: Yes, non-modifiable Min. Value: 3 Max. Value: 15 Accepts Null: No
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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
Additional Information
Data Source Hierarchy
EMS PCR
Associated Edit Checks
Rule ID Level Message
0227 1 Value is not a valid menu option
0228 2 Field cannot be blank
Data format: [Alpha/Numeric] single entry Pick-list: Yes Min. Value: NA Max. Value: NA Accepts Null: No
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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
Additional Information
Data Source Hierarchy
EMS PCR
Associated Edit Checks
Rule ID Level Message
0229 1 Invalid value
0230 2 Field cannot be blank
Data format: [Numeric] single entry Pick-list: No Min. Value: Auto-calculated Max. Value: Auto-calculated Accepts Null: No
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INJURY INFORMATION
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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
Relevant value for data element
Additional Information
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.
Data Source Hierarchy
EMS PCR
Associated Edit Checks
Rule ID Level Message
0231 1 Date is not valid
0232 1 Date out of range
0233 2 Field cannot be blank
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
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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
Relevant value for data element
Additional Information
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.
Data Source Hierarchy
EMS PCR
Associated Edit Checks
Rule ID Level Message
0241 1 Time is not valid
0242 1 Time out of range
0243 2 Field cannot be blank
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
0250 2 Field cannot be Not Applicable
Data format: [Numeric] single entry Pick-list: No Min. Value: 0 Max. Value: 2359 Accepts Null: No
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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
Additional Information
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.
Data Source Hierarchy
1. EMS PCR
2. ED Records
3. Billing sheets
Associated Edit Checks
Rule ID Level Message
0251 1 Invalid value (ICD-10-CM only)
0252 2 Field cannot be blank
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)
0256 2 Field cannot be Not Applicable
Data format: [Numeric] single entry Pick-list: YES Min. Value: 0 Max. Value: 9 Accepts Null: NO
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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
Relevant value for data element
Additional Information
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.
Data Source Hierarchy
1. EMS report form
2. ED records
3. Billing Sheets, Medical records coding sheets
Associated Edit Checks
Rule ID Level Message
0257 1 Invalid value
0258 2 Field cannot be blank
0259 2 Field cannot be Not Applicable
Data format: Numeric Pick-list: No Min. Value: NA Max. Value: NA Accepts Null: Yes
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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
Associated Edit Checks
Rule ID Level Message
0260 1 Invalid value (US only)
0261 2 Field cannot be blank
0262 2 Field must be Not Applicable (Non-US)
Data format: [character, 30] single entry Pick-list: Yes non-modifiable Min. Value: NA Max. Value: NA Accepts Null: Yes
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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.
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
Associated Edit Checks
Rule ID Level Message
0263 1 Invalid value (US only)
0264 2 Field cannot be blank
0265 2 Field must be Not Applicable (Non-US)
Data format: [character, 30] single entry Pick-list: Yes non-modifiable Min. Value: NA Max. Value: NA Accepts Null: Yes
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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.
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
Associated Edit Checks
Rule ID Level Message
0266 1 Invalid value (US only)
0267 2 Field cannot be blank
0268 2 Field must be Not Applicable (Non-US)
Data format: [character, 30] single entry Pick-list: Yes non-modifiable Min. Value: NA Max. Value: NA Accepts Null: Yes
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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.
Data Source Hierarchy
1. EMS Report Form 2. ED Records
Associated Edit Checks
Rule ID Level Message
0269 1 Invalid value
0270 2 Field cannot be blank
0271 2 Field cannot be Not Applicable
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
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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
Associated Edit Checks
Rule ID Level Message
0273 1 Value is not a valid menu option
0274 2 Field cannot be blank
Data format: [CHARACTER, 30] single entry Pick-list: Yes non-modifiable Min. Value: NA Max. Value: NA Accepts Null: Yes
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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)
Associated Edit Checks
Rule ID Level Message
0275 1 Value is not a valid menu option
0276 2 Field cannot be blank
Data format: [CHARACTER, 2] single entry Pick-list: Yes non-modifiable Min. Value: NA Max. Value: NA Accepts Null: Yes
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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
Associated Edit Checks
Rule ID Level Message
0277 1 Value is not a valid menu option
0278 2 Field cannot be blank
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.
Data format: [CHARACTER, 1] single entry Pick-list: Yes non-modifiable Min. Value: NA Max. Value: NA Accepts Null: Yes
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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
Associated Edit Checks
Rule ID Level Message
0282 1 Value is not a valid menu option
0283 2 Field cannot be blank
Data Format: [character, 15] single entry Pick list: Yes, non-modifiable Min Value: N/A Max Value: N/A Accepts Null Value: Yes
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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
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Associated Edit Checks
Rule ID Level Message
0284 1 Value is not a valid menu option
0285 2 Field cannot be blank
Data Format: [character, 15] single entry Picklist: Yes, non-modifiable Min Value: N/A Max Value: N/A Accepts Null Value: Yes
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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.
Additional Information
Data Source Hierarchy
EMS Patient Care Record
ED Patient Care Record
Associated Edit Checks
Rule ID Level Message
0286 1 Value is not a valid menu option
0287 2 Field cannot be blank
Data Format: [numeric, 3] single entry Picklist: No Min Value: 0 Max Value: 20 Accepts Null Value: Yes
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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
Rule ID Level Message
0288 1 E-Code is not a valid ICD-10-CM code (ICD-10 CM only)
0289 2 Field cannot be blank
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)
0293 2 Field cannot be Not Applicable
Data Format: [character, 6] single entry Picklist: Yes Min Value: NA Max Value: NA Accepts Null Value: Yes
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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
Rule ID Level Message
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
0296 2 Field cannot be blank
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
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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
Additional Information
Data Source Hierarchy
EMS Patient Record
ED Patient Record
Associated Edit Checks
Rule ID Level Message
0298 1 Value is not a valid menu option
0299 2 Field cannot be blank
Data Format: [character, 2] single entry Pick list: Yes Min Value: 0 Max Value: 15 Accepts Null Value: Yes
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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
Additional Information
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.
Data Source Hierarchy
EMS Patient Care Record
ED Patient Care Record.
Associated Edit Checks
Rule ID Level Message
0300 1 Value is not a valid menu option
0301 2 Field cannot be blank
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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
0304 2 Field cannot be Not Applicable
Data Format: [character, 2] single entry Pick list: Yes non-modifiable Min Value: 0 Max Value: 99 Accepts Null Value: Yes
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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.
Additional Information
Data Source Hierarchy
EMS Patient Care Record
ED Patient Care Record
Associated Edit Checks
Rule ID Level Message
0305 1 Invalid value
Data Format: [character] free text Pick list: No Min Value: NA Max Value: NA Accepts Null Value: Yes
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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
Additional Information
Evidence of the use of child restraint may be reported or observed.
Only completed when Protective Devices include “Child Restraint.”
Data Source Hierarchy
EMS Patient care record
Associated Edit Checks
Rule ID Level Message
0306 1 Value is not a valid menu option
0307 2 Field cannot be blank
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
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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.)
Additional Information
Check all that apply.
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.
Data Source Hierarchy
EMS Patient care record
Associated Edit Checks
Rule ID Level Message
0309 1 Value is not a valid menu option
0310 2 Field cannot be blank
0311 2 Field cannot be Not Applicable when Protective Device is 8 (Airbag Present)
Data Format: [character, 1] Pick list: Yes Min Value: 1 Max Value: 4 Accepts Null Value: Yes
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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
Additional Information
This includes, but is not limited to, a report of child, elder, spouse or intimate partner
physical abuse.
Data Source Hierarchy
Associated Edit Checks
Rule ID Level Message
0312 1 Value is not a valid menu option
0313 2 Field cannot be Not Applicable
0314 2 Field cannot be blank
Data Format: [character, 1] Pick list: Yes Min Value: 1 Max Value: 2 Accepts Null Value: Yes
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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
Additional Information
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.
Data Source Hierarchy
Associated Edit Checks
Rule ID Level Message
0315 1 Value is not a valid menu option
0316 3 Field cannot be blank
0317 3 Field should not be Not Applicable when Report of Physical Abuse = 1 (Yes)
Data Format: [character, 1] Pick list: Yes Min Value: 1 Max Value: 2 Accepts Null Value: Yes
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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
Additional Information
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 Source Hierarchy
Associated Edit Checks
Rule ID Level Message
0318 1 Value is not a valid menu option
0319 2 Field cannot be blank
Data Format: [character, 1] Pick list: Yes
Min Value: 1 Max Value: 2 Accepts Null Value: Yes
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REFER IN INFORMATION
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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
Additional Information
Information for this section only applies to the transferring hospital.
Data Source Hierarchy
EMS Patient Care Record
Records from Transferring Facility
Associated Edit Checks
Rule ID Level Message
0320 1 Date is not valid
0321 1 Date out of range
0322 2 Field cannot be blank
Data Format: [date] single entry Pick list: No Min Value: 01/01/2008 Max Value: Current Date Accepts Null Value: Yes
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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
Additional Information
Information for this section only applies to the transferring hospital.
Data Source Hierarchy
EMS Patient Care Record
Records from Transferring Facility
Associated Edit Checks
Rule ID Level Message
0323 1 Time is not valid
0324 1 Time out of range
0325 2 Field cannot be blank
Data Format: [TIME] single entry Pick list: No Min Value: 0:00 Max Value: 23:59 Accepts Null Value: Yes
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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
Additional Information
Information for this section only applies to the transferring hospital.
Data Source Hierarchy
EMS Patient Care Record
Records from Transferring Facility
Associated Edit Checks
Rule ID Level Message
0326 1 Date is not valid
0327 1 Date out of range
0328 2 Field cannot be blank
Data Format: [DATE] single entry Pick list: No Min Value: 01/01/2008 Max Value: Current date Accepts Null Value: Yes
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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
Additional Information
Information for this section only applies to the transferring hospital.
Data Source Hierarchy
EMS Patient Care Record
Records from Transferring Facility
Associated Edit Checks
Rule ID Level Message
0329 1 Time is not valid
0330 1 Time out of range
0331 2 Field cannot be blank
Data Format: [TIME] single entry Pick list: No Min Value: 0:00 Max Value: 23:59 Accepts Null Value: Yes
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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
Additional Information
Auto-calculated
Information for this section only applies to the transferring hospital.
Data Source Hierarchy
EMS Patient Care Record
Records from Transferring Facility
Associated Edit Checks
Rule ID Level Message
0332 1 Invalid value
Data Format: [NUMERIC] single entry Pick list: No Min Value: 0 Max Value: NA Accepts Null Value: Yes
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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
Additional Information
Information for this section only applies to the transferring hospital.
Data Source Hierarchy
EMS Patient Care Record
Records from Transferring Facility
Associated Edit Checks
Rule ID Level Message
0333 1 Value is not a valid menu option
Data Format: [numeric] single entry Pick list: Yes non-modifiable Min Value: 1 Max Value: 9 Accepts Null Value: Yes
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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
1 Regional Medical Center of San Jose
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
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67 Washoe/Renown Hospital
24 Watsonville Community
Additional Information
Information for this section only applies to the transferring hospital.
Data Source Hierarchy
EMS Patient Care Record
Records from Transferring Facility
Associated Edit Checks
Rule ID Level Message
0334 1 Value is not a valid menu option
Data Format: [numeric] single entry Pick list: Yes non-modifiable Min Value: 1 Max Value: 99 Accepts Null Value: Yes
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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.
Additional Information
Information for this section only applies to the transferring hospital.
Data Source Hierarchy
EMS Patient Care Record
Records from Transferring Facility
Associated Edit Checks
Rule ID Level Message
0335 1 Invalid value
Data Format: [character 75] single entry Pick list: No Min Value: NA Max Value: NA Accepts Null Value: Yes
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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
Additional Information
Information in this section only applies to a patient who is transferred to your facility
from another acute care facility
Data Source Hierarchy
Records from Transferring Facility
Associated Edit Checks
Rule ID Level Message
0336 1 Value is not a valid menu option
Data Format: [Alpha, 1] Pick list: Yes Min Value: NA Max Value: NA Accepts Null Value: Yes
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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
Additional Information
Information in this section only applies to a patient who is transferred to your facility
from another acute care facility
Data Source Hierarchy
Records from Transferring Facility
Associated Edit Checks
Rule ID Level Message
0337 1 Value is not a valid menu option
Data Format: [Alpha, 1] Pick list: Yes Min Value: NA Max Value: NA Accepts Null Value: Yes
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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
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
Additional Information
Information in this section only applies to a patient who is transferred to your facility from
another acute care facility
Data Source Hierarchy
Patient ED medical record
Associated Edit Checks
Rule ID Level Message
0338 1 Value is not a valid menu option
Data Format: [Numeric, 1] Pick list: Yes Min Value: NA Max Value: NA Accepts Null Value: Yes
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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)
Additional Information
Information in this section only applies to a patient who is transferred to your facility from
another acute care facility
Data Source Hierarchy
Patient ED medical record
Associated Edit Checks
Rule ID Level Message
0339 1 Value is not a valid menu option
Data Format: [Numeric, 1] Pick list: Yes Min Value: NA Max Value: NA Accepts Null Value: Yes
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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
Additional Information
Information in this section only applies to a patient who is transferred to your facility from
another acute care facility.
Readmissions to the Observation Unit will not be included in the registry.
Data Source Hierarchy
Patient ED medical record
Associated Edit Checks
Rule ID Level Message
0340 1 Value is not a valid menu option
Data Format: [Alpha, 1] Pick list: Yes Min Value: NA Max Value: NA Accepts Null Value: Yes
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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
Additional Information
Information in this section only applies to a patient who is transferred to your facility from
another acute care facility.
Data Source Hierarchy
Patient records from transferring facility.
Associated Edit Checks
Rule ID Level Message
0341 1 Value is not a valid menu option
Data Format: [Alpha, 1] Pick list: YES Min Value: NA Max Value: NA Accepts Null Value: Yes
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EMERGENCY DEPARTMENT INFORMATION
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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
Relevant value for data element
Additional Information
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).
Data Source Hierarchy
ED patient records
Associated Edit Checks
Rule ID Level Message
0342 1 Date is not valid
0343 1 Date out of range
0344 2 Field cannot be blank
0345 2 Field cannot be Not Known/Not Recorded
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
0355 2 Field cannot be Not Applicable
Data Format: [DATE, 1] Pick list: Yes Min Value: 07/01/2008 Max Value: Current date Accepts Null Value: No
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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
Additional Information
• 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).
Data Source Hierarchy
1. ED Records
2. EMS Report Form
Associated Edit Checks
Rule ID Level Message
0356 1 Time is not valid
0357 1 Time out of range
0358 2 Field cannot be blank
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
0364 2 Field cannot be Not Applicable
Data Format: [TIME, 1] Pick list: No Min Value: 00:01 Max Value: 23:59 Accepts Null Value: No
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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
Relevant value for data element
Additional Information
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.
Data Source Hierarchy
1. Physician’s Progress Notes
2. Billing Sheet / Medical Records Coding Summary Sheet 3. Hospital Discharge Summary
Associated Edit Checks
Rule ID Level Message
0365 1 Date is not valid
0366 1 Date out of range
0367 2 Field cannot be blank
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
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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
Relevant value for data element
Additional Information
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.
Data Source Hierarchy
1. ED Records
2. Hospital Record
Associated Edit Checks
Rule ID Level Message
0375 1 Time is not valid
0376 1 Time out of range
0377 2 Field cannot be blank
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
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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
Additional Information
Data Source Hierarchy
1. ED Records
Associated Edit Checks
Rule ID Level Message
0383 1 Invalid value
Data Format: [NUMERIC] Pick list: No Min Value: 0 Max Value: NA Accepts Null Value: No
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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
Additional Information
Data Source Hierarchy
1. ED Records
Associated Edit Checks
Rule ID Level Message
0384 1 Value is not a valid menu option
Data Format: [NUMERIC, 1] Pick list: Yes Min Value: NA Max Value: NA Accepts Null Value: No
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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
Additional Information
Data Source Hierarchy
Patient ED medical record
Associated Edit Checks
Rule ID Level Message
0385 1 Value is not a valid menu option
Data Format: [NUMERIC, 1] Pick list: Yes Min Value: NA Max Value: NA Accepts Null Value: No
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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
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
Additional Information
Data Source Hierarchy
Patient ED medical record
Associated Edit Checks
Rule ID Level Message
0386 1 Value is not a valid menu option
Data Format: [NUMERIC, 1] Pick list: Yes Min Value: 1 Max Value: 99 Accepts Null Value: No
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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
03 Telemetry/Stepdown
04 Home with Services
09 Home without Services
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
11 Transferred to Another Hospital
Additional Information
Readmissions to the Observation Unit will not be included in the registry. (SCC)
Data Source Hierarchy
Patient ED medical record
Associated Edit Checks
Rule ID Level Message
0387 1 Value is not a valid menu option
0388 2 Field cannot be blank
0389 2 Field cannot be Not Known/Not Recorded
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
Data Format: [NUMERIC, 1] Pick list: Yes Min Value: NA Max Value: NA Accepts Null Value: No
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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
Additional Information
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.
Data Source Hierarchy
1. ED Records
Associated Edit Checks
Rule ID Level Message
0394 1 Value is not a valid menu option
0395 2 Field cannot be blank
0396 3 Field should not be Not Known/Not Recorded
0397 2 Field cannot be Not Applicable
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
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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
• Relevant value for data element
Additional Information
Data Source Hierarchy
1. ED Records
2. Physician’s Progress Notes
Associated Edit Checks
Rule ID Level Message
0400 1 Date is not valid
0401 1 Date out of range
0402 2 Field cannot be blank
Data Format: [DATE, 1] Pick list: No
Min Value: 07/01/2008 Max Value: CURRENT DATE Accepts Null Value: No
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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
• Relevant value for data element
Additional Information
Data Source Hierarchy
1. ED Records
2. Physician’s Progress Notes
Associated Edit Checks
Rule ID Level Message
0403 1 Time is not valid
0404 1 Time out of range
0405 2 Field cannot be blank
Data Format: [TIME, 1] Pick list: No
Min Value: 00:00 Max Value: 23:59 Accepts Null Value: No
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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
• Relevant value for data element
Additional Information
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.
Data Source Hierarchy
1. ED Records
2. Physician’s Progress Notes
Associated Edit Checks
Rule ID Level Message
0406 1 Invalid valid
0407 2 Field cannot be blank
0408 3 Pulse rate exceeds the max of 299
0409 2 Field cannot be Not Applicable
Data Format: [NUMERIC, 1] Pick list: No Min Value: NA Max Value: NA Accepts Null Value: No
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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
• Relevant value for data element
Additional Information
• Used to calculate Revised Trauma Score - ED (adult & pediatric)
• If available, complete additional field: Initial ED/Hospital Respiratory Assistance.
Please note that first recorded/hospital vitals do not need to be from the same assessment.
Data Source Hierarchy
1. ED Records
2. Physician’s Progress Notes
Associated Edit Checks
Rule ID Level Message
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.
0411 2 Field cannot be blank
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.
0413 2 Field cannot be Not Applicable
Data Format: [NUMERIC, 1] Pick list: No Min Value: NA Max Value: NA Accepts Null Value: Yes
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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
Additional Information
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.
Please note that first recorded/hospital vitals do not need to be from the same assessment.
The null value “Not Applicable” is used if “Initial ED/Hospital Respiratory Rate” is “Not Known/Not Recorded.”
Data Source Hierarchy
1. ED Records
2. Physician’s Progress Notes
Associated Edit Checks
Rule ID Level Message
0414 1 Value is not a valid menu option
0415 2 Field cannot be blank
Data Format: [ALPHA, 1] Pick list: No Min Value: NA Max Value: NA Accepts Null Value: Yes
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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
• Relevant value for data element
Additional Information
If available, complete additional field: Initial ED/Hospital Supplemental Oxygen.
Please note that first recorded/hospital vitals do not need to be from the same assessment.
Data Source Hierarchy
1. ED Records
2. Physician’s Progress Notes
Associated Edit Checks
Rule ID Level Message
0416 1 Pulse oximetry is outside the valid range of 0 - 100
0417 2 Field cannot be blank
0418 2 Field cannot be Not Applicable
Data Format: [NUMERIC, PERCENTAGE 1] Pick list: No Min Value: NA Max Value: NA Accepts Null Value: Yes
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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
Additional Information
Only completed if a value is provided for Initial ED/Hospital Oxygen Saturation, otherwise report as “Not Applicable”.
Please note that first recorded/hospital vitals do not need to be from the same assessment.
Data Source Hierarchy
1. ED Records
2. Physician’s Progress Notes
Associated Edit Checks
Rule ID Level Message
0419 1 Value is not a valid menu option
0420 2 Field cannot be blank
Data Format: [ALPHA/NUMERIC, 1] Pick list: Yes Min Value: NA Max Value: NA Accepts Null Value: Yes
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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
• Relevant value for data element
Additional Information
• Used to calculate Revised Trauma Score - ED (adult & pediatric)
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.
Data Source Hierarchy
1. ED Records
2. Physician’s Progress Notes
Associated Edit Checks
Rule ID Level Message
0421 1 Invalid value
0422 2 Field cannot be blank
0423 3 SBP value exceeds the max of 300
0424 2 Field cannot be Not Applicable
Data Format: [NUMERIC, 1] Pick list: No Min Value: 0 Max Value: 300 Accepts Null Value: Yes
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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
ED/hospital arrival.
Field Values
• Relevant value for data element
Additional Information
• Used to calculate Revised Trauma Score - ED (adult & pediatric)
Please note that first recorded/hospital vitals do not need to be from the same assessment.
Data Source Hierarchy
1. ED Records
2. Physician’s Progress Notes
Associated Edit Checks
Rule ID Level Message
0425 1 Invalid value
0426 2 Field cannot be blank
0427 3 DBP value exceeds the max of 300
Data Format: [NUMERIC, 1] Pick list: No Min Value: NA Max Value: NA Accepts Null Value: Yes
Santa Clara County Trauma Registry Data Dictionary
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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
ED/hospital arrival.
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
Additional Information
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.
Please note that first recorded/hospital vitals do not need to be from the same assessment.
Data Source Hierarchy
1. ED Records
2. Physician’s Progress Notes
Associated Edit Checks
Rule ID Level Message
0428 1 Value is not a valid menu option
0429 2 Field cannot be blank
0430 2 Field cannot be Not Applicable
Data Format: [NUMERIC, 1] Pick list: Yes Min Value: NA Max Value: NA Accepts Null Value: Yes
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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
Pediatric (≤ 2 years):
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
Additional Information
Used to calculate Overall GCS – ED Score.
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.
Please note that first recorded/hospital vitals do not need to be from the same assessment.
Data Source Hierarchy
1. ED Records
2. Physician’s Progress Notes
Associated Edit Checks
Rule ID Level Message
0431 1 Value is not a valid menu option
0432 2 Field cannot be blank
0433 2 Field cannot be Not Applicable
Data Format: [NUMERIC, 1] Pick list: YES Min Value: NA Max Value: NA Accepts Null Value: YES
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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
4 Withdrawal from pain
3 Flexion to pain
2 Extension to pain
1 No motor response
Adult:
6 Obeys commands
5 Localizing pain
4 Withdrawal from pain
3 Flexion to pain
2 Extension to pain
1 No motor response
Additional Information
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 withdraws from a painful stimulus,” a Motor GCS of 4 may be recorded, IF there is no other contradicting documentation.
Please note that first recorded/hospital vitals do not need to be from the same assessment.
Data Source Hierarchy
1. ED Records 2. Physician’s Progress Notes
Associated Edit Checks
Rule ID Level Message
0434 1 Value is not a valid menu option
0435 2 Field cannot be blank
0436 2 Field cannot be Not Applicable
Data Format: [NUMERIC, 1] Pick list: Yes Min Value: NA Max Value: NA Accepts Null Value: Yes
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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
• Relevant value for data element
Additional Information
• 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.
Please note that first recorded/hospital vitals do not need to be from the same assessment.
Data Source Hierarchy
1. ED Records
2. Physician’s Progress Notes
Associated Edit Checks
Rule ID Level Message
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
0439 2 Field cannot be blank
0440 2 Field cannot be Not Applicable
Data Format: [NUMERIC, AUTO-CALCULATED1] Pick list: No Min Value: NA Max Value: NA Accepts Null Value: Yes
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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
Additional Information
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
2. Physician’s Progress Notes
Associated Edit Checks
Rule ID Level Message
0441 1 Value is not a valid menu option
0442 2 Field cannot be blank
Data Format: [ALPHA, 1] Pick list: No Min Value: NA Max Value: NA Accepts Null Value: Yes
Santa Clara County Trauma Registry Data Dictionary
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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
• Relevant value for data element
Additional Information
Recorded in centimeters.
May be based on family or self-report.
Please note that first recorded/hospital vitals do not need to be from the same assessment.
Data Source Hierarchy
1. Triage/Trauma/Hospital Flow Sheet
2. Nurses Notes/Flow Sheet 3. Pharmacy Record
Associated Edit Checks
Rule ID Level Message
0443 1 Invalid value
0444 2 Field cannot be blank
0445 3 Height exceeds the max of 244 (cm)
0446 2 Field cannot be Not Applicable
Data Format: [NUMERIC, 1] Pick list: No Min Value: NA Max Value: NA Accepts Null Value: Yes
Santa Clara County Trauma Registry Data Dictionary
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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
• Relevant value for data element
Additional Information
Recorded in kilograms.
May be based on family or self-report.
Please note that first recorded/hospital vitals do not need to be from the same assessment.
Data Source Hierarchy
1. Triage/Trauma/Hospital Flow Sheet
2. Nurses Notes/Flow Sheet 3. Pharmacy Record
Associated Edit Checks
Rule ID Level Message
0447 1 Invalid value
0448 2 Field cannot be blank
0449 3 Weight exceeds the max of 907 (kg)
0450 2 Field cannot be Not Applicable
Data Format: [NUMERIC, 1] Pick list: No Min Value: NA Max Value: NA Accepts Null Value: Yes
Santa Clara County Trauma Registry Data Dictionary
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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
Additional Information
Data Source Hierarchy
PCR
ED medical Record
Associated Edit Checks
Rule ID Level Message
0451 1 Invalid value
0452 2 Field cannot be blank
Data Format: [NUMERIC/AUTO-CALCULATED,1] Pick list: No Min Value: NA Max Value: NA Accepts Null Value: Yes
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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
• Relevant value for data element
Additional Information
Please note that first recorded/hospital vitals do not need to be from the same assessment.
Data Source Hierarchy
1. ED Records
2. Physician’s Progress Notes
Associated Edit Checks
Rule ID Level Message
0453 1 Invalid value
0454 2 Field cannot be blank
0455 3 Temperature exceeds the max of 45.0 Celsius
0456 2 Field cannot be Not Applicable
Data Format: [NUMERIC,1] Pick list: No
Min Value: NA Max Value: NA Accepts Null Value: Yes
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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)
Additional Information
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.
Data Source Hierarchy
1. Lab Results
2. Transferring Facility Records
Associated Edit Checks
Rule ID Level Message
0457 1 Value is not a valid menu option
0458 2 Field cannot be blank
0459 2 Field cannot be Not Applicable
Data Format: [NUMERIC,1] Pick list: Yes Min Value: NA Max Value: NA Accepts Null Value: Yes
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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
Additional Information
Alcohol screen may be administered at any facility, unit, or setting treating this patient
event.
Data Source Hierarchy
1. Lab Results
2. Transferring Facility Records
Associated Edit Checks
Rule ID Level Message
0460 1 Value is not a valid menu option
0461 2 Field cannot be blank
0462 2 Field cannot be Not Applicable
Data Format: [NUMERIC,1] Pick list: Yes Min Value: NA Max Value: NA Accepts Null Value: Yes
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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.
Additional Information
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.
Data Source Hierarchy
1. Lab Results
2. Transferring Facility Records
Associated Edit Checks
Rule ID Level Message
0463 1 Value is not a valid menu option
0464 2 Field cannot be blank
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
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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
Additional Information
Data Source Hierarchy
1. ED Records
2. Physician’s Progress Notes Associated Edit Checks
Rule ID Level Message
0466 1 Value is not a valid menu option
0467 2 Field cannot be blank
Data Format: [NUMERIC,1] Pick list: YES Min Value: NA Max Value: NA Accepts Null Value: YES
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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
Additional Information
Data Source Hierarchy
1. ED records
Associated Edit Checks
Rule ID Level Message
0468 1 Invalid value
Data Format: [ALPHA,1] Pick list: No Min Value: NA Max Value: NA Accepts Null Value: Yes
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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
Additional Information
Data Source Hierarchy
1. Radiology Records
2. ED Records
Associated Edit Checks
Rule ID Level Message
0469 1 Time is not valid
0470 1 Time out of range
0471 2 Field cannot be blank
Data Format: [TIME,1] Pick list: Yes Min Value: 00:01 Max Value: 23:59 Accepts Null Value: No
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TRAUMA TEAM INFORMATION
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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
Additional Information
Data Source Hierarchy
1. ED Records
2. Physician’s Progress Notes
Associated Edit Checks
Rule ID Level Message
0472 1 Value is not a valid menu option
Data Format: [ALPHA,1] Pick list: Yes Min Value: NA Max Value: NA Accepts Null Value: Yes
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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
Additional Information
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
Data Source Hierarchy
1. ED Records
2. Physician’s Progress Notes
Associated Edit Checks
Rule ID Level Message
0473 1 Date is not valid
0474 1 Date out of range
0475 2 Field cannot be blank
Data Format: [NUMERIC DATE,1] Pick list: No
Min Value: 07/01/2008 Max Value: Current Date Accepts Null Value: Yes
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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
• Relevant value for data element
Additional Information
Data Source Hierarchy
1. ED Records
2. Physician’s Progress Notes
Associated Edit Checks
Rule ID Level Message
0476 1 Time is not valid
0477 1 Time out of range
0478 2 Field cannot be blank
Data Format: [NUMERIC TIME,1] Pick list: No
Min Value: 00:01 Max Value: 23:59 Accepts Null Value: Yes
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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
Additional Information
Data Source Hierarchy
1. ED Records
Associated Edit Checks
Rule ID Level Message
0479 1 Value is not a valid menu option
Data Format: [ALPHA,1] Pick list: Yes
Min Value: NA Max Value: NA Accepts Null Value: Yes
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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)
Additional Information
Data Source Hierarchy
Associated Edit Checks
Rule ID Level Message
0480 1 Value is not a valid menu option
Data Format: [ALPHA,1] Pick list: Yes Min Value: NA Max Value: NA Accepts Null Value: No
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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
Additional information
Data Source Hierarchy
Associated Edit Checks
Rule ID Level Message
0481 1 Value is not a valid menu option
Data Format: [ALPHA,1] Pick list: Yes Min Value: NA Max Value: NA Accepts Null Value: No
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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
• Relevant value for data element
Additional Information
• 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.
Data Source Hierarchy
1. ED Records
2. EMS Report Form
Associated Edit Checks
Rule ID Level Message
0482 1 Time is not valid
0483 1 Time out of range
0484 2 Field cannot be blank
Data Format: [NUMERIC,1] Pick list: No Min Value: 00:01 Max Value: 23:59 Accepts Null Value: No
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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
• Relevant value for data element
Additional Information
Data Source Hierarchy
1. ED Records
2. EMS Report Form
Associated Edit Checks
Rule ID Level Message
0485 1 Time is not valid
0486 1 Time out of range
0487 2 Field cannot be blank
Data Format: [NUMERIC,1] Pick list: No Min Value: 00:01 Max Value: 23:59 Accepts Null Value: No
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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
• Relevant value for data element
Additional Information
Data Source Hierarchy
1. ED Records
2. EMS Report Form
Associated Edit Checks
Rule ID Level Message
0488 1 Time is not valid
0489 1 Time out of range
0490 2 Field cannot be blank
Data Format: [TIME,1] Pick list: No Min Value: 00:01 Max Value: 23:59 Accepts Null Value: No
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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
Additional Information
• Auto-calculated field
Data Source Hierarchy
1. ED Records
2. EMS Report Form
Associated Edit Checks
Rule ID Level Message
0491 1 Value is not a valid menu option
Data Format: [ALPHA,1] Pick list: Yes Min Value: NA Max Value: NA Accepts Null Value: No
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CONSULTS INFORMATION
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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
Additional Information
Data Source Hierarchy
1. ED Records
2. EMS Report Form
Associated Edit Checks
Rule ID Level Message
0492 1 Date is not valid
0493 1 Date out of range
0494 2 Field cannot be blank
Data Format: [ALPHA,1] Pick list: Yes Min Value: NA Max Value: NA Accepts Null Value: No
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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
Additional Information
Data Source Hierarchy
1. ED Records
2. EMS Report Form
Associated Edit Checks
Rule ID Level Message
0495 1 Time is not valid
0496 1 Time out of range
0497 2 Field cannot be blank
Data Format: [TIME,1] Pick list: No Min Value: 00:01 Max Value: 23:59 Accepts Null Value: No
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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
Additional Information
Data Source Hierarchy
1. ED Records
2. EMS Report Form
Associated Edit Checks
Rule ID Level Message
0498 1 Date is not valid
0499 1 Date out of range
0500 2 Field cannot be blank
Data Format: [DATE,1] Pick list: No
Min Value: 07/01/2008 Max Value: CURRENT DATE Accepts Null Value: No
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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
Additional Information
Data Source Hierarchy
1. ED Records
2. EMS Report Form
Associated Edit Checks
Rule ID Level Message
0501 1 Time is not valid
0502 1 Time out of range
0503 2 Field cannot be blank
Data Format: [TIME,1] Pick list: No
Min Value: 00:01 Max Value: 23:59 Accepts Null Value: No
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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
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
Additional Information
Select from the above pick list for consult service
Data Source Hierarchy
1. ED Records
2. EMS Report Form
Associated Edit Checks
Rule ID Level Message
0504 1 Value is not a valid menu option
Data Format: [NUMERIC,1] Pick list: Yes Min Value: 00 Max Value: 99 Accepts Null Value: No
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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
Additional Information
Date Source Hierarchy
1. ED record
Associated Edit Checks
Rule ID Level Message
0505 1 Value is not a valid menu option
Data Format: [NUMERIC,1] Pick list: Yes Min Value: NA Max Value: NA Accepts Null Value: No
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LABORATORY INFORMATION
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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
Data Source Hierarchy
ED record
Lab results
MD Documentation
Associated Edit Checks
Rule ID Level Message
0506 1 Value is not a valid menu option
0507 1 Date out of range
0508 1 Date is not valid
Data Format: [ALPHA,1] Pick list: No Min Value: NA Max Value: NA Accepts Null Value: Yes
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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)
Additional Information
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)
Data Source Hierarchy
1. Lab results
2. ED Records
Associated Edit Checks
Rule ID Level Message
0509 1 Value is not a valid menu option
Data Format: [NUMERIC,1] Pick list: Yes Min Value: NA Max Value: NA Accepts Null Value: No
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INPATIENT INFORMATION
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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
03 Telemetry/Stepdown
04 Home with Services
09 Home without Services
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
11 Transferred to Another Hospital
Additional Information
Readmissions to the Observation Unit will not be included in the registry.
Data Source Hierarchy
1. ED Records
Associated Edit Checks
Rule ID Level Message
0510 1 Value is not a valid menu option
Data Format: [NUMERIC,1] Pick list: Yes Min Value: NA Max Value: NA Accepts Null Value: No
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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
• Relevant value for data element
Additional Information
If the patient arrives by interfacility transport the date selected is the date the patient
comes to your facility.
Data Source Hierarchy
ED Records
Patient Care Record
Associated Edit Checks
Rule ID Level Message
0511 1 Date is not valid
0512 1 Date out of range
0513 2 Field cannot be blank
Data Format: [date, 8] Pick list: No Min Value: 07/01/2008 Max Value: Current Date Accepts Null Value: Yes
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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
• Relevant value for data element
Additional Information
Data Source Hierarchy
ED Records
Patient Care Record
Associated Edit Checks
Rule ID Level Message
0514 1 Time is not valid
0515 1 Time out of range
0516 2 Field cannot be blank
Data Format: [time, 4] Pick list: No Min Value: 00:01 Max Value: 23:59 Accepts Null Value: Yes
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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
• Relevant value for data element
Additional Information
Data Source Hierarchy
ED Records
Patient Care Record
Associated Edit Checks
Rule ID Level Message
0517 1 Date is not valid
0518 1 Date out of range
0519 2 Field cannot be blank
Data Format: [date, 8] Pick list: No Min Value: 07/01/2008 Max Value: Current Date Accepts Null Value: Yes
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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
• Relevant value for data element
Additional Information
Data Source Hierarchy
ED Records
Patient Care Record
Associated Edit Checks
Rule ID Level Message
0520 1 Time is not valid
0521 1 Time out of range
0522 2 Field cannot be blank
Data Format: [time, 4] Pick list: No Min Value: 00:01 Max Value: 23:59 Accepts Null Value: Yes
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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.
Additional Information
Data Source Hierarchy
ED Records
Patient Care Record
Associated Edit Checks
Rule ID Level Message
0523 1 Invalid value
Data Format: [numeric, 4] Pick list: No Min Value: 0 Max Value: NA Accepts Null Value: Yes
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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
Relevant value for data element
Manually calculated (SCC)
Additional Information
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
0/02/11 09:00 01/02/11 18:00 2 days (episodes on 2 separate calendar days)
E. 01/01/11 01:00 01/01/11 16:00
01/02/11 09:00 01/02/11 21:00 2 days (episodes on 2 separate calendar days)
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
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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
01/03/11 18:00 01/03/11 20:00 3 days (patient was on Vent on 3 separate calendar days)
Data Source Hierarchy
ED Records
Patient Care Record
Associated Edit Checks
Rule ID Level Message
0524 1 Total Ventilator Days is outside the valid range of 1 – 575
0525 2 Field cannot be blank
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
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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
Additional Information
In units C
Data Source Hierarchy
Patient Care Record
Associated Edit Checks
Rule ID Level Message
0528 1 Invalid value
Data Format: [numeric, 3] Pick list: No Min Value: 90 Max Value: 107 Accepts Null Value: Yes
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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
Relevant value for data element
Auto-calculated (SCC)
Additional Information
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 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.
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
0/02/11 09:00 01/02/11 18:00 2 days (episodes on 2 separate calendar days)
E. 01/01/11 01:00 01/01/11 16:00
01/02/11 09:00 01/02/11 21:00 2 days (episodes on 2 separate calendar days)
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)
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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)
Data Source Hierarchy
Associated Edit Checks
Rule ID Level Message
0529 1 Total ICU Length of Stay is outside the valid range of 1 - 575
0530 2 Field cannot be blank
0531 3 Total ICU Length of Stay is greater than the difference between ED/Hospital Arrival Date and Hospital Discharge Date
0532 3 Value is greater than 365, please verify this is correct
Data Format: [numeric, ] Pick list: No Min Value: NA Max Value: NA Accepts Null Value: Yes
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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
Additional Information
Data Source Hierarchy
Associated Edit Checks
Rule ID Level Message
0533 1 Invalid value
Data Format: [auto-calculated] Pick list: No Min Value: NA Max Value: NA Accepts Null Value: Yes
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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
Additional Information
Data Source Hierarchy
Associated Edit Checks
Rule ID Level Message
0534 1 Invalid value
Data Format: [auto-calculated] Pick list: No Min Value: NA Max Value: NA Accepts Null Value: Yes
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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
Relevant value for data element
Auto-Calculated (SCC)
Additional Information
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
0/02/11 09:00 01/02/11 18:00 2 days (episodes on 2 separate calendar days)
E. 01/01/11 01:00 01/01/11 16:00
01/02/11 09:00 01/02/11 21:00 2 days (episodes on 2 separate calendar days)
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
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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
01/03/11 18:00 01/03/11 20:00 3 days (patient was on Vent on 3 separate calendar days)
Data Source Hierarchy
ED Records
Patient Care Record
Associated Edit Checks
Rule ID Level Message
0535 1 Total Ventilator Days is outside the valid range of 1 - 575
0536 2 Field cannot be blank
0537 4 Total Ventilator Days should not be greater than the difference between ED/Hospital Arrival Date and Hospital Discharge Date
0538 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
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HOSPITAL PROCEDURE INFORMATION
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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
12 Spinal Cord Acute Care
09 Step Down
10 TCU
25 Telemetry
18 Trauma Room
Additional Information
Enter null values as applicable
Data Source Hierarchy
Patient Care Record
Associated Edit Checks
Rule ID Level Message
0539 1 Value is not a valid menu option
Data Format: [numeric, 2] Pick list: Yes Min Value: NA Max Value: NA Accepts Null Value: Yes
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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
Relevant value for data element
Additional Information
Enter null value if applicable
Data Source Hierarchy
Patient care record
Associated Edit Checks
Rule ID Level Message
0540 1 Invalid value
Data Format: [numeric, 2] Pick list: No Min Value: NA Max Value: NA Accepts Null Value: Yes
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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
• Relevant value for data element
Additional Information
Data Source Hierarchy
1. OR Records
2. Radiology Records 3. ED Records 4. Progress Notes
Associated Edit Checks
Rule ID Level Message
0541 1 Date is not valid
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
0549 2 Field cannot be blank
Data Format: [numeric, 2] Pick list: No Min Value: NA Max Value: NA Accepts Null Value: Yes
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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
• Relevant value for data element
Additional Information
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.
Data Source Hierarchy
1. Radiology readings / Lab results
2. ED Records
Associated Edit Checks
Rule ID Level Message
0550 1 Time is not valid
0551 1 Time out of range
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
0557 2 Field cannot be blank
Data Format: [numeric, 2] Pick list: No Min Value: NA Max Value: NA Accepts Null Value: Yes
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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
Additional Information
Calculated in minutes
Data Source Hierarchy
1 Patient care record
2 Operative report
Associated Edit Checks
Rule ID Level Message
0558 1 Invalid value
Data Format: [time] single entry Pick list: No Min Value: N A Max Value: NA Accepts Null Value: Yes
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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.
Additional Information
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
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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
Data Source Hierarchy
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
Associated Edit Checks
Rule ID Level Message
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
0561 2 Field cannot be blank
0562 4 Field should not be Not Applicable unless patient had no procedures performed
0563 1 Invalid value (ICD-10 CA only)
Data Format: [numeric] single entry Pick list: Yes
Min Value: N A Max Value: NA Accepts Null Value: Yes
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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
Additional Information
Data Source Hierarchy
4. Radiology readings/Lab results
5. ED records
6. Operative Records
Associated Edit Checks
Rule ID Level Message
0564 1 Invalid value
Data Format: [alpha] single entry Pick list: Yes
Min Value: N A Max Value: NA Accepts Null Value: Yes
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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
• Relevant value for data element
Additional Information
Pick list specific to each center
Data Source Hierarchy
1. OR Records
Associated Edit Checks
Rule ID Level Message
0565 1 Value is not a valid menu option
Data Format: [alpha] multiple entries Picklist: Yes, facility-modifiable Min Value: N/A Max Value: N/A Accepts Null Value: Yes
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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
Data Source Hierarchy
1. OR Records
Associated Edit Checks
Rule ID Level Message
0566 1 Value is not a valid menu option
Data Format: [alpha] multiple entries Picklist: Yes, facility-modifiable Min Value: N/A Max Value: N/A Accepts Null Value: Yes
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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
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
Additional Information
Data source hierarchy
OR records
Associated Edit Checks
Rule ID Level Message
0567 1 Value is not a valid menu option
Data Format: [numeric] multiple entries Picklist: Yes, facility-modifiable Min Value: N/A Max Value: N/A Accepts Null Value: Yes
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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
Additional information
Data Source Hierarchy
1 ED record
2 Operating room record
Associated Edit Checks
Rule ID Level Message
0568 1 Invalid value
Data Format: [numeric] auto-calculated Picklist: No Min Value: N/A Max Value: N/A Accepts Null Value: Yes
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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
• Relevant value for data element
Additional Information
Amount administered in 0-4 hours.
Data Source Hierarchy
1. ED Records
2. Blood Bank Records
Associated Edit Checks
Rule ID Level Message
0569 1 Invalid value
Data Format: [numeric] Picklist: No Min Value: N/A Max Value: N/A Accepts Null Value: Yes
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HOSPITAL PROCEDURE INFORMATION SCC County Element PR_15 State Element NA
FIRST OR TEMPERATURE National Element NA
Definition
Initial temperature of patient on OR admission if within 24 hours.
Field Values
Relevant to data collected
Additional Information
Document in Celsius.
Data Source Hierarchy
Operating room record
Associated Edit Checks
Rule ID Level Message
0570 1 Invalid value
Data Format: [alpha] Picklist: Yes Min Value: N/A Max Value: N/A Accepts Null Value: Yes
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HOSPITAL PROCEDURE INFORMATION SCC County Element PR_16 State Element NA
TEMPERATURE UNITS National Element NA
Definition
The temperature taken in Celsius.
Field Values
C (Celsius)
Additional Information
Data Source Hierarchy
OR Record
Associated Edit Checks
Rule ID Level Message
0571 1 Value is not a valid menu option
Data Format: [Alpha] Picklist: Yes Min Value: N/A Max Value: N/A Accepts Null Value: Yes
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HOSPITAL PROCEDURE INFORMATION SCC County Element PR_17 State Element NA
TIME TO FIRST OR VISIT National Element NA
Definition
This is the auto-calculated time from patient arrival to OR.
Field Values
Auto calculated
Additional Information
Data Source Hierarchy
OR record
Associated Edit Checks
Rule ID Level Message
0572 1 Invalid value
Data Format: [NUMERIC] auto-calculation Picklist: No Min Value: N/A Max Value: N/A Accepts Null Value: Yes
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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
Additional Information
• 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.
Data Source Hierarchy
1. Radiology Records
2. ED Records
Associated Edit Checks
Rule ID Level Message
0573 1 Value is not a valid menu option
Data Format: [ALPHA,1] Pick list: Yes Min Value: NA Max Value: NA Accepts Null Value: No
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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
Additional Information
• Orbital X-Ray with contrast
• Nasal Sinus X-Ray with contrast
• Kidney X-Ray with contrast (Intravenous pyelogram) Data Source Hierarchy
1. Radiology Records
2. ED Records
Associated Edit Checks
Rule ID Level Message
0574 1 Value is not a valid menu option
Data Format: [ALPHA, 1] Pick list: Yes Min Value: NA Max Value: NA Accepts Null Value: No
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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
Data Source Hierarchy
1. Radiology Records
2. ED Records
Associated Edit Checks
Rule ID Level Message
0575 1 Value is not a valid menu option
Data Format: [ALPHA,1] Pick list: Yes Min Value: NA Max Value: NA Accepts Null Value: No
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CO-MORBIDITIES INFORMATION
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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)
Additional Information
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.
Check all that apply.
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Data Source Hierarchy
Associated Edit Checks
Rule ID Level Message
0576 1 Value is not a valid menu option
0577 2 Field cannot be blank
Data Format: [NUMERIC] Picklist: Yes Min Value: N/A Max Value: N/A Accepts Null Value: Yes
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Diagnosis Information
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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
Associated Edit Checks
Rule ID Level Message
0578 1 Invalid value (ICD-10 CM only)
0579 2 Field cannot be blank
0580 2 At least one diagnosis must be provided and meet inclusion criteria. (ICD-10 CM only)
0581 4 Field should not be Not Known/Not Recorded
0582 1 Invalid value (ICD-10 CA 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
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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
Additional Information
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.
Data Source Hierarchy
Hospital medical records
PCR
Associated Edit Checks
Rule ID Level Message
0584 1 Invalid value
0585 3 AIS codes are not valid AIS 05, Update 08 codes
0586 2 Field cannot be blank
0587 2 Field cannot be Not Applicable
Data Format: [NUMERIC] Picklist: Yes Min Value: N/A Max Value: N/A Accepts Null Value: Yes
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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
Additional Information
The field value (7) “Not Possible to Assign” would be chosen if it is not possible to assign
a severity to an injury.
Data Source Hierarchy
Hospital medical records
PCR
Associated Edit Checks
Rule ID Level Message
0588 1 Value is not a valid menu option
0589 2 Field cannot be blank
0590 2 Field cannot be Not Applicable
Data Format: [NUMERIC] Picklist: Yes
Min Value: 1 Max Value: 9 Accepts Null Value: Yes
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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
Additional Information
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
Data Source Hierarchy
Associated Edit Checks
Rule ID Level Message
0591 1 Locally calculated ISS is outside the valid range of 1 - 75
0592 3 Value should be the sum of three squares
0593 2 Field cannot be blank
Data Format: [NUMERIC] Picklist: Yes Min Value: 1 Max Value: 75 Accepts Null Value: Yes
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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
Additional Information
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.
Data Source Hierarchy
Hospital Patient record
Associated Edit Checks
Rule ID Level Message
0594 1 Value is not a valid menu option
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
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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
Additional Information
Data Source Hierarchy
Associated Edit Checks
Rule ID Level Message
0596 1 Invalid value
Data Format: [NUMERIC,Auto calculated] Picklist: NA Min Value: N/A Max Value: N/A Accepts Null Value: No
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DISCHARGE INFORMATION
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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
Relevant value for data element
Additional Information
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.
Data Source Hierarchy
Patient Medical Record
Associated Edit Checks
Rule ID Level Message
0597 1 Date is not valid
0598 1 Date out of range
0599 2 Field cannot be blank
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
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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
Relevant value for data element
Additional Information
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.
Data Source Hierarchy
Patient medical record
Associated Edit Checks
Rule ID Level Message
0610 1 Time is not valid
0611 1 Time out of range
0612 2 Field cannot be blank
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
0618 2 Field must be Not Applicable when ED Discharge Disposition = 4,6,9,10, or 11
0619 2 Field must be Not Applicable when ED Discharge Disposition = 5 (Died)
Data Format: [TIME] Picklist: NA Min Value: NA Max Value: NA Accepts Null Value: No
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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
Additional Information
Data Source Hierarchy
Associated Edit Checks
Rule ID Level Message
0620 1 Invalid value
Data Format: [auto-calculated] Picklist: NA Min Value: NA Max Value: NA Accepts Null Value: No
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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
Additional Information
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.
Data Source Hierarchy
Patient medical record
Associated Edit Checks
Rule ID Level Message
0621 1 Value is not a valid menu option
0622 2 Field cannot be blank
0623 2 Field must be Not Applicable when ED Discharge Disposition = 5 (Died)
0624 2 Field must be Not Applicable when ED Discharge Disposition = 4,6,9,10, or 11
0625 2 Field cannot be Not Applicable
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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
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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
Additional Information
Data Source Hierarchy
Patient medical Record
Associated Edit Checks
Rule ID Level Message
0627 1 Value is not a valid menu option
Data Format: [Alpha] Picklist: Yes Min Value: NA Max Value: NA Accepts Null Value: No
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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
Additional Information
Data Source Hierarchy
Patient Medical Record
Associated Edit Checks
Data Format: [Numeric] Picklist: Yes Min Value: NA Max Value: NA Accepts Null Value: No
Rule ID Level Message
0628 1 Value is not a valid menu option
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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
1 Regional Medical Center of San Jose
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
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Additional Information
Data Source Hierarchy
Patient Medical Record
Associated Edit Checks
Rule ID Level Message
0629 1 Value is not a valid menu option
Data Format: [Numeric] Picklist: Yes Min Value: NA Max Value: NA Accepts Null Value: No
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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
Additional Information
Data Source Hierarchy
Patient medical record
Associated Edit Checks
Rule ID Level Message
0630 1 Value is not a valid menu option
Data Format: [Alpha ] Picklist: Yes
Min Value: NA Max Value: NA Accepts Null Value: No
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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
Additional Information
Patients who are from adjacent counties may be repatriated to their home county when
stable
Data Source Hierarchy
Patient Medical Record
Associated Edit Checks:
Rule ID Level Message
0631 1 Value is not a valid menu option
Data Format: [Alpha] Picklist: Yes Min Value: NA Max Value: NA Accepts Null Value: No
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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
Additional Information
No Fault Automobile, Workers Compensation, and Blue Cross/Blue Shield should be
captured as Private/Commercial Insurance.
Data Source Hierarchy
Patient Medical Record
Associated Edit Checks
Rule ID Level Message
0632 1 Value is not a valid menu option
0633 2 Field cannot be blank
0634 2 Field cannot be Not Applicable
Data Format: [Numeric] Picklist: Yes
Min Value: NA Max Value: NA Accepts Null Value: No
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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.
Additional Information
Data Source Hierarchy
Patient medical records
Patient billing records
Associated Edit Checks
Rule ID Level Message
0635 1 Invalid value
Data Format: [Numeric] Picklist: Yes
Min Value: NA Max Value: NA Accepts Null Value: No
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DEATH INFORMATION
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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
12 Spinal Cord Acute Care
09 Step Down
10 TCU
25 Telemetry
18 Trauma Room
Additional Information
Data Source Hierarchy
Patient Care Record
Associated Edit Checks
Rule ID Level Message
0636 1 Value is not a valid menu option
Data Format: [Numeric] Picklist: Yes Min Value: NA Max Value: NA Accepts Null Value: No
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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
Additional Information
Data Source Hierarchy
Patient Medical Record
Associated Edit Checks
Rule ID Level Message
0637 1 Value is not a valid menu option
Data Format: [Numeric] Picklist: Yes
Min Value: NA Max Value: NA Accepts Null Value: No
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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
Additional Information
Data Source Hierarchy
Patient medical record
Associated Edit Checks
Rule ID Level Message
0638 1 Value is not a valid menu option
Data Format: [Alpha] Picklist: Yes Min Value: NA Max Value: NA Accepts Null Value: No
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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
Additional Information
Data Source Hierarchy
Patient Medical Record
Associated Edit Checks
Rule ID Level Message
0639 1 Value is not a valid menu option
Data Format: [Alpha] Picklist: Yes Min Value: NA Max Value: NA Accepts Null Value: No
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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
Additional Information
Data Source Hierarchy
Patient medical Record
Associated Edit Checks
Rule ID Level Message
0640 1 Value is not a valid menu option
Data Format: [Alpha] Picklist: Yes
Min Value: NA Max Value: NA Accepts Null Value: No
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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
Additional Information
Data Source Hierarchy
Patient Medical Record
Associated Edit Checks
Rule ID Level Message
0641 1 Value is not a valid menu option
Data Format: [Numeric] Picklist: Yes Min Value: NA Max Value: NA Accepts Null Value: No
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DEATH INFORMATION SCC County Element DE_07 State Element NA AUTOPSY ID National Element NA
Definition
Coroner ID # found on autopsy report.
Field Values
• Relevant value for data element
Additional Information
Data Source Hierarchy
Associated Edit Checks
Rule ID Level Message
0642 1 Invalid value
Data Format: [Numeric] Picklist: No Min Value: NA Max Value: NA Accepts Null Value: No
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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
Additional Information
Data Source Hierarchy
Patient Medical Record
Associated Edit Checks
Rule ID Level Message
0643 1 Value is not a valid menu option
Data Format: [Alpha] Picklist: Yes Min Value: NA Max Value: NA Accepts Null Value: No
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SURGEON SPECIFIC REPORTING
**The field(s) in this section are optional**
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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
Relevant value for data element
Additional Information
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 Source Hierarchy
Associated Edit Checks
Rule ID Level Message
0645 1 Invalid value
0646 2 Field cannot be blank
Data Format: [Numeric] Picklist: No Min Value: NA Max Value: NA Accepts Null Value: No
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QUALITY ASSURANCE INFORMATION
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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.
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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,
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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
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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.
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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
January 2016 CDC Criterion LCBI 2:
Patient has at least one of the following signs or symptoms: fever (>38◦C), chills, or hypotension
AND
Organism(s) identified in blood is not related to an infection at another site.
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
January 2016 CDC Criterion LCBI 3:
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
Organism(s) identified in blood is not related to an infection at another site.
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
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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)
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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
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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
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
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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.
Code Operative Procedure Code Operative Procedure
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.
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(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
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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
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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.