ARIZONA STATE TRAUMA REGISTRY (ASTR) REDUCED DATA SET ONLY - ASTR 2012 REDUCED DATA SET DATA DICTIONARY - Version 3.0 Last updated 1-9-12 REQUIRED DATA ITEMS/FORMAT SPECIFICATIONS FOR DESIGNATED LEVEL IV TRAUMA CENTERS, NON-DESIGNATED HOSPITALS & ALS BASE HOSPITALS THAT CHOOSE TO SUBMIT THE REDUCED DATA SET (Level IV / non-designated facilities have the option to submit a full or reduced data set) Effective for ED/Hospital Arrival Dates January 1, 2012 - December 31, 2012 Supplement with database information from vendor specifications. Please refer to the Appendices and Index at the end of the document for more information *This document refers to the ASTR reduced data set values only. WHEN REPORTING ON ASTR DATA, REFER TO THE FULL DATA SET DICTIONARY. ASTR Database Information / Limitations: Only patients meeting the ASTR Trauma Patient Inclusion Definition are included in the ASTR database. ASTR inclusion criteria were changed in 2008, and again in 2012. (See Appendix I for criteria.) The ASTR database does not contain all fatal and non-fatal injury events within Arizona. Injured patients are NOT captured in the ASTR database if they: 1) Died at the scene and were not transferred to a trauma center, 2) Were treated only at a non-reporting hospital, or 3) Patient did not meet the ASTR trauma patient inclusion criteria. A limited number of Arizona hospitals submit data to ASTR, but all designated trauma centers report data to ASTR. (Refer to Appendix A1 for list of ASTR reporting hospitals.) Designated Level I, Level II, and Level III Trauma Centers are required to submit to ADHS the full data set as outlined in this data dictionary. (See Appendix J.) Level IV Trauma Centers, Non-Designated Hospitals, and ALS Base Hospitals may collect the full data set, but do have the option of submitting a reduced data set (See Appendix J). Duplicate records may exist in the ASTR database for patients who transferred from one reporting hospital to another during the course of their injury management. Many required data element definitions and drop down menus were changed for 2008, with smaller changes and addtions in 2011 & 2012. It is important to account for these changes when comparing trauma registry data from multiple years. This dictionary pertains to reduced data set records with ED/Hospital Arrival Dates in 2012. A separate reduced data dictionary exists for ED/Hospital Arrival Dates 2009-2011, and for the FULL data set. For questions regarding the Reduced Data Set, please contact the EMS & Trauma Data Manager at 602-364-3164. For more information on the Arizona State Trauma Registry, please go to the ADHS website link: http://www.azdhs.gov/bems/TraumaRegistry.htm Column Descriptions (for this document): Data elements shaded in gray are ASTR-only database fields and are NOT required for submission by reporting hospitals. Data Element Description = Name of ASTR required data element. Please use data element name when submitting an ASTR data request. Table Name = ASTR Oracle table name in which the data element values are stored. **Not e on ASTR Trauma One® Orac le tbltables: In thASTROthe ASTR Orac le dtbdatabase, "ACCTNO" is the common key fie ld and the MAINDATA ta ble is the pr imary ta ble. The "ACCTNO" field is auto-generated by the ASTR Trauma One database. Field Name = Field name as stored in ASTR database. *Database field names may not correspond to the type of data being recorded - refer to data element description. Data Value = Indicates the actual data values (short text) stored in database for reporting. Data values submitted to ASTR must match the state-required picklist values and must be UPPERCASE. Primary/Subpicklist Descriptions = Long text description of the picklist values, as users view them on the data entry screen. When mapping data for interfacing, use the data values (short text). When the registrar selects a long text description from the data entry screen, the corresponding short text data value is stored in the database for reporting purposes. Definition & Comments = Brief definition of the data element, including important data entry instructions for registrars entering the trauma data. Also includes comments on acceptable Null Values. User notes: Below is a list of the data elements required for the ASTR reduced data set. Required fields should not be left blank. Not Documented (coded as *ND) indicates that the information requested is not known or not recorded. Not Applicable (coded as *NA) means that the field does not apply to that situation. For example, the Admission Date does not apply (*NA) if the patient was never admitted to your hospital. ASTR ASTR DATA VALUES - the actual codes PRIMARY AND SUBPICKLIST DESCRIPTIONS DATA ELEMENT DATABASE TABLE (short text) stored in database for (long text displayed in data entry to help user DEFINITION & COMMENTS (including when null values are appropriate) DESCRIPTION FIELD NAME NAME reporting and data interfacing select the correct data value) (system only)* DEMOGRAPHIC SECTION Account Number** MAINDATA ACCTNO Unique account number generated by the database for each record. In the ASTR database, this is referred to as the Lancet Account No. or Patient Account No. **ASTR Reporting note: ACCTNO is the common key field in the ASTR Oracle tables. MAINDATA is the primary table. Automatically generated by system. This number (Account Number), in addition to the prefix of the Site ID, makes up the "State Unique ID". Arizona State Trauma Registry (ASTR) 2012 Data Dictionary - REDUCED Data Set only - version 3.0 Page 1 of 53 ASTR ASTR DATA VALUES - the actual codes PRIMARY AND SUBPICKLIST DESCRIPTIONS DATA ELEMENT DATABASE TABLE (short text) stored in database for (long text displayed in data entry to help user DEFINITION & COMMENTS (including when null values are appropriate) DESCRIPTION FIELD NAME NAME reporting and data interfacing select the correct data value) (system only)* Registration Number MAINDATA EMRNUM Unique number assigned by your hospital for this specific episode of care. May also be referred to in hospital billing as "Patient Control Number", "Patient Account Number" or "Patient Encounter Number". It is the unique number for this hospital visit. For linking purposes, this number should match what your facility submits to HDD. Do not add leading zeros or trailing zeros unless they are an official part of your hospital numbering system. Not Documented and Not Applicable should not be used. Medical Record Number MAINDATA MEDRECNUM Hospital record number through which the patient's medical history can be retrieved. May also be referred to as the " Patient Health Record Number ". Number is unique for the patient, but not unique for this hospital visit. For linking purposes, this number should match what your facility submits to HDD. Do not add leading or trailing zeros unless they are an official part of your hospital numbering system. Not Documented and Not Applicable should not be used. ED/Hospital Arrival First recorded arrival date into your emergency department (or hospital) for this Date* TRA TR_ENT_DT mmddyyyy injury event. If patient did not enter your hospital through the ED (e.g., direct admit), enter the date of first contact with the patient for this injury event. *Determines the case date range for data submission and date range for ASTR data reporting. Valid entry required for all records. Field is used to calculate Patient Age, ED LOS and Total Hospital LOS. Not Documented (*ND) and Not Applicable (*NA) should not be used. Field should not be left blank. Vendor note: ED/Hospital Arrival Date is stored in both the Demographic and Trauma pages of the ASTR data entry view. These fields have the same table and field name. Admission Status at Admission status of the patient at your facility. Indicates to ASTR if patient had ED Reporting Facility STAT2008 INP_STATUS ED_ADMIT Admitted through ED at your hospital care, inpatient care or both. DIR_ADMIT Direct Admit at your hospital Not Documented (*ND) should not be used. Not Applicable should not be used. If patient was not admitted, enter one of the ED choices from picklist. If patient left AMA before admission, select "Seen in your ED ED_TRANSFR Seen in your ED then transferred out by EMS and released..." Seen in your ED and released (or refer priv. ED_RELEASE vehicle) ED_DEATH DOA or Died in ED Patient Last Name MAINDATA LASTNAME Patient's last name as it appears in medical record. Not Documented (*ND) may be used. Not Applicable should not be used. Patient First Name MAINDATA FIRSTNAME Patient's first name as it appears in medical record. Not Documented (*ND) may be used. Not Applicable should not be used. Patient Middle Initial MAINDATA MIDINIT Patient's middle initial as it appears in medical record. Not Documented (*ND) and Not Applicable (*NA) may be used. Social Security Number PERHIST PT_SSN 9 digit number XXXXXXXXX Patient's Social Security Number as it appears in medical record. Not Documented (*ND) should be used when patient has a SSN, but number is unknown. Not Applicable (*NA) should be used if patient does not have a SSN. Arizona State Trauma Registry (ASTR) 2012 Data Dictionary - REDUCED Data Set only - version 3.0 Page 2 of 53 ASTR ASTR DATA VALUES - the actual codes PRIMARY AND SUBPICKLIST DESCRIPTIONS DATA ELEMENT DATABASE TABLE (short text) stored in database for (long text displayed in data entry to help user DEFINITION & COMMENTS (including when null values are appropriate) DESCRIPTION FIELD NAME NAME reporting and data interfacing select the correct data value) (system only)* Patient Date of Birth PERHIST BIRTHDAY mmddyyyy The patient's date of birth (DOB). System will autocalculate Patient Age from entry of DOB and ED/Hospital Arrival Date. If DOB is unknown, enter Not Documented (*ND) for DOB and then enter an estimated age for patient.