Kansas Trauma Registry Data Dictionary
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KANSAS TRAUMA REGISTRY DATA DICTIONARY Kansas Department of Health and Environment Bureau of Community Health Systems Revised July, 2014 Questions about the Kansas Trauma Registry Data Dictionary 785-296-5459 [email protected] Questions about the operation of Collector Software 1-800-344-3668 ext. 4 [email protected] Questions on the Kansas Trauma Program 785-296-1210 Kansas Trauma Registry State-Required Core Data Elements Demographic Information Facility Number Last 4 digits of SS# Trauma Number Patient’s Residence (City, County, State, Zip-Code) Submit Record to KDHE Date of Birth ED/Arrival Date/Time Age Frist Closed Date Gender Entry Form Number Race Medical Record Number Ethnicity Trauma Bracelet Number Prehospital Injury Information Incident Date/Time Injury Location City, County, State, Zip-Code Primary Injury Type Protective Devices – Restraint ICD-9-CM E-code (External Cause of Injury) Protective Devices – Airbag Description of Injury Circumstanced Protective Devices - Equipment Place of Injury Category Other Prehospital Information – Section Repeats for each Transport Provider Mode of Transportation Arrived Hospital Date/Time Linked Record Systolic/Diastolic Blood Pressure EMS Agency Heart Rate Run Sheet Received/Complete Unassisted Respiratory Rate Call Received Date/Time Glasgow Coma Score (Motor, Eye, Verbal, Total) Dispatched Date/Time Glasgow Coma Score Assessment Qualifier En Route Date/Time Revised Trauma Score (unweighted) Arrived Location Date/Time Airway Patient Contact Date/Time CPR Departed Location Date/Time Fluids Emergency Department Arrived From Base Deficit Transferring Facility ID Temperature Transferring Facility Medical Record Number Glasgow Coma Score (Motor, Eye, Verbal, Total) Activation Glasgow Coma Score Assessment Qualifier Injury Mechanism/Off Road Vehicle Revised Trauma Score (unweighted) Signs of Life ETOH/BAC Test Results ED Disposition/Admit to Drug Screen Results OR Disposition Abdominal CT Results Systolic/Diastolic Blood Pressure Chest CT Results Heart Rate Head CT Results Unassisted Respiratory Rate Airway Oxygen Administered Trauma Team Leader Oxygen Saturation Trauma Team Leader Called/Arrived on Time Procedures ICD-9-CM Procedure Code Days on Ventilator Procedure Date, Start Time, Stop Time Diagnoses ICD-9-CM Diagnosis Code-Injury Injury Severity Scores (ISS and TRISS) Abbreviated Injury Score (AIS) ICD-9-MC Diagnosis Code-Comorbid Condition Outcomes Discharge Date/Time Disabilities at Discharge-Ambulation Score/Qualifier Discharge Status Disabilities at Discharge-Communication Score/Qualifier Discharge to (Facility ID) Primary Payer Source EMS Mode of Transport for discharged patient Secondary Payer Source EMS called and arrived date/time Total Hospital Charges Days in Intensive Care Unit Total Hospital Collection Disabilities at discharge-Feeding Score/Qualifier Autopsy Performed Quality Assurance/Quality Improvement Non-Injury-Related Occurrences (complications) Last Updated September, 2014 Kansas Trauma Registry Data Dictionary Table of Contents Section 1 DEMOGRAPHIC Section 2 PREHOSPITAL Section 3 INTERMEDIATE FACILITY Section 4 EMERGENCY DEPARTMENT Section 5 PROCEDURES Section 6 DIAGNOSIS Section 7 OUTCOME Section 8 QUALITY ASSURANCE/QUALITY IMPROVEMENT Appendix: GLOSSARY OF TERMS KANSAS TRAUMA REGISTRY DATA DICTIONARY Demographic SECTION 1 – DEMOGRAPHIC Facility Number* .................................................................................................................. 3 Trauma Number* ................................................................................................................. 3 Core/Comprehensive Data .................................................................................................. 3 Submit Record to KDHE* .................................................................................................... 4 First Closed Date/Time* ...................................................................................................... 4 First Transfer Date/Time* .................................................................................................... 4 ED Arrival Date - Month* ..................................................................................................... 5 ED Arrival Date - Day* ......................................................................................................... 5 ED Arrival Date - Year*........................................................................................................ 5 ED Arrival Time - Hour* ....................................................................................................... 6 ED Arrival Time - Minute* .................................................................................................... 6 Entry Form Number* ........................................................................................................... 7 Medical Record Number* .................................................................................................... 7 Trauma Bracelet Number* ................................................................................................... 7 Patient Social Security Number* ......................................................................................... 8 Visit Number ........................................................................................................................ 8 Patient’s Last Name ............................................................................................................ 8 Patient’s First Name ............................................................................................................ 8 Patient’s Middle Name ........................................................................................................ 9 Patient’s Home Zip Code 1* ................................................................................................ 9 Patient’s Home Zip Code 2 .................................................................................................. 9 Patient’s Street Address 1 ................................................................................................. 10 Patient’s Street Address 2 ................................................................................................. 10 Patient’s Home City* ......................................................................................................... 10 Patient’s Home City – If Other* .......................................................................................... 11 Patient’s County of Residence* ......................................................................................... 11 Patient’s State of Residence* ............................................................................................ 11 Date of Birth - Month* ........................................................................................................ 12 Date of Birth - Day* ........................................................................................................... 12 Date of Birth – Year* ......................................................................................................... 12 Age* .................................................................................................................................. 13 Age Units* ......................................................................................................................... 13 Patient’s Race* .................................................................................................................. 13 Patient’s Gender* .............................................................................................................. 14 Patient’s Ethnicity* ............................................................................................................. 14 Occupation ........................................................................................................................ 15 Demographic Memo .......................................................................................................... 16 *Items are CORE (State Required) Data Elements. Demographics Page 1 July 2014 KANSAS TRAUMA REGISTRY DATA DICTIONARY Demographic Demographic – Demographic Tab Copyright © 2014 Digital Innovation, Inc. All Rights Reserved. CONFIDENTIAL Demographics Page 2 July 2014 KANSAS TRAUMA REGISTRY DATA DICTIONARY Demographic Facility Number* Window Location: Data Field Name: Demographic : Demographic INST_NUM State Required: Type of Field: Length: Yes Integer 7 DEFINITIONS Facility Number – The number assigned by the program that identifies the facility. This number cannot be changed. INSTRUCTIONS The Facility Number will be provided by the program. Trauma Number* Window Location: Data Field Name: Demographic : Demographic TRAUMA_NUM State Required: Type of Field: Length: Yes Integer 8 DEFINITIONS Trauma Number – The number assigned by the program that identifies the patient record. This number should not be changed once the case is submitted to the state. Please consult with Digital Innovation or KTR Staff before changing this number. INSTRUCTIONS Trauma Number is incremented by 1 automatically. Use direct keyboard entry to change the number if needed. Core/Comprehensive Data Window Location: Data Field Name: Demographic : Demographic CORE_COMP State Required: Type of Field: Length: No Integer 1 DEFINITIONS Core data – State-required data elements and selected demographic information. Comprehensive data – The entire