North Carolina Trauma Registry (NCTR) Data Dictionary NCTR Data Dictionary
Introduction
This document, the North Carolina Trauma Registry (NCTR) Data Dictionary, was created using the data dictionary published by the National Trauma Registry of the American College of Surgeons (NTRACS), with modifications specific to the North Carolina Trauma Registry. It is to be used in lieu of the NTRACS data
It provides a brief summary of every data point used in North Carolina, and notes where there are custom options standard throughout the State. It does not cover those data items that are customized or by each site specifically and not used statewide.
Some data points are not downloaded to the State, i.e., the Central Data Collection Agency. These datapoints are noted with a "d" in the Download Scenario column. Therefore, the statewide registry does not include these data points, although each individual hospital has them.
The column labeled Download Scenario contains information on whether datapoints are to be downloaded to the Central Data Collection Agency (the State) and whether datapoints are sent to the National Trauma Data Bank (NTDB). This column contains one of three values: h d: This variable is not to be downloaded to the State and is not sent to NTDB h s: This variable is to be downloaded to the State, but the data are not sent to NTDB h s,n: This variable is to be downloaded to the State, and may be forwarded to the NTDB.
For the NC Custom Data Points, field type and size information have been included in the Definitions column. The field types are character ( C ), numeric ( N ), and date ( D ) and logic (L). Numeric variables can have decimal places. A numeric variable with a size of 4 with no decimal places would be representative as N4.0. A numeric variable with a size of 4 and 2 decimal places would be represented as N4.2.
The column labeled Datapoint History describes the history of changes to each datapoint and/or discussion, issues, or notes regarding the datapoint. Each change or comment is dated. This column was added in the Jan 2001 version of this data dictionary.
For further information, please contact:
Sharon Kromhout-Schiro, Ph.D. Director of Research and Communications North Carolina Trauma Registry, Central Data Collection Agency UNC School of Medicine BioInformatics Building, Room 2126 130 Mason Farm Road UNC Department of Surgery, CB#7050 Chapel Hill, NC 27599-7050 (919) 966-6263 / Fax: (919) 966-6009 e-mail: [email protected] Pager: (919) 216-5029 NCTR Data Dictionary
NCTR Patient Definition
Patients who have an ICD9 diagnosis code in 800-959.9 and who are either admitted to the hospital for greater than 23:59 hours (24 hours or more) from an ED, die in the ED, are DOA, are transferred from the ED to the OR or ICU, or who are transferred to another hospital should be entered into the Trauma Registry.
Minimum Requirements for Data Entry
a. Data verification: Data must be verified by each hospital prior to being sent to NCTR. b. Records on 100% of patients must be entered into the NTRACS data system within 90 days of death, transfer, or discharge from the hospital. The Reimbursed Charges datapoint should be completed at 6 months from the date of death, transfer, or discharge from the hospital. c. Downloads are due on Jan 31, Apr 30, Jul 31, and Oct 31 of each year. Downloads must include all records for patients who died, were transferred, or were discharged 90 days or more prior to the download date. d. Data submitted to the CDCA must include valid entries in all required fields marked for submission to the CDCA in the latest version of the NCTR Data Dictionary. e. In years that a hospital has a site visit, records must be entered into the NTRACS data system to meet the requirements listed in the current site visit chart selection document which can be accessed through the NC-EMS website (http://www.ncems.org/). NCTR Data Dictionary
Global Changes
April 1, 2005
I. Deactivations The following Version 2.5 (V2.5) options may be deactivated from the pick lists; it is important not to delete the options as they are still valid for previous versions. -1 -3 D Not Done/Doc Pending
II. New Lists In addition to the Hospital and Chemical Sedation lists there are 3 new lists as follows: EMS Provider List EMS_ReferHosp Drugs
You may add options to your pick lists as needed; this will limit adding items you will not use. Please ensure that you do not have items in your NTRACS picklist that are not on the approved list. If you need to add any other valuest, please contact Annette O'Dell or Sharon Schiro to have the values added to the approved list.
III. New Data Items On the Injury Screen there is a second E-Code field enabling 2 codes to be assigned to a patient when the need arises. On the Diagnosis Screen there is a new, auto calculating data item (NISS). The NISS is calculated by adding the top 3 AIS scores squared. This differs from the ISS score in that the top 3 could all be in the same body region. Table of Contents
No Datapoint Tab 1 MedRecNo Demographics 2 SocSecNo Demographics 3 PFName Demographics 4 PMI Demographics 5 PLName Demographics 6 Sex Demographics 7 Race Demographics 8 DOB Demographics 9 Man_Age Demographics 10 Age Demographics 11 PAddress Demographics 12 PAddrss2 Demographics 13 PCity Demographics 14 PState Demographics 15 PZIPCode Demographics 16 PCounty Demographics 17 PCountry Demographics 18 Occupation Demographics 19 InjDate Injury 20 InjTime Injury 21 InjCity Injury 22 InjState Injury 23 InjZIP Injury 24 InjCounty Injury 25 InjCountry Injury 26 ECode Injury 26.1 ECode2 Injury 27 Blunt Injury 28 InjSite Injury 29 CrashRpt Injury 30 Position Injury 31 Safety Injury 32 InjComment Injury 33 EMS Pre-Hospital 34 AmbRun Pre-Hospital 35 ScEMSRpt Pre-Hospital 36 Sconditn Pre-Hospital 37 DispDate Pre-Hospital 38 DispTime Pre-Hospital 39 ArrTime Pre-Hospital 40 SceneTime Pre-Hospital 41 DeptTime Pre-Hospital 42 TranspTime Pre-Hospital 43 ArrHosp1 Pre-Hospital 44 Spulse Pre-Hospital 45 SResp Pre-Hospital 46 SBP Pre-Hospital 47 Seye Pre-Hospital
NCTR-DataDictionary-22Jun2005 Table of Contents
No Datapoint Tab 48 SVrb Pre-Hospital 49 SMtr Pre-Hospital 50 SGCS Pre-Hospital 51 STS Pre-Hospital 52 Pre_CalcAQ Pre-Hospital 53 Man_SGCS Pre-Hospital 54 Man_STS Pre-Hospital 55 Pre_Manaq Pre-Hospital 56 Pre-CPR Pre-Hospital 57 Pre_Airway Pre-Hospital 58 Pre_Mast Pre-Hospital 59 Pre_Fluid Pre-Hospital 60 PreNeedlTh Pre-Hospital 61 PreTubeTho Pre-Hospital 62 PreDrug Pre-Hospital 63 HospTrf Referring Hospital 64 Ref_ArrDat Referring Hospital 65 Ref_ArrTim Referring Hospital 66 Ref_DCDate Referring Hospital 67 Ref_DCTime Referring Hospital 68 ReferHosp Referring Hospital 69 Ref_MD Referring Hospital 70 Ref_Pulse Referring Hospital 71 Ref_Resp Referring Hospital 72 Ref_BP Referring Hospital 73 Ref_Eye Referring Hospital 74 Ref_Vrb Referring Hospital 75 Ref_Mtr Referring Hospital 76 Ref_GCS Referring Hospital 77 REF_TS Referring Hospital 78 Ref_CalcAQ Referring Hospital 79 ManRef_GCS Referring Hospital 80 ManRef_TS Referring Hospital 81 Ref_ManAQ Referring Hospital 82 RefHeadCT Referring Hospital 83 RefChestCT Referring Hospital 84 RefPerLav Referring Hospital 85 RefAorto Referring Hospital 86 RefArterio Referring Hospital 87 RefAbdUlso Referring Hospital 88 RefAbdCT Referring Hospital 89 RefAirway Referring Hospital 90 RefCPR Referring Hospital 91 RefOR Referring Hospital 92 RefICU Referring Hospital 93 RefDrug Referring Hospital 94 Dir_Admit ED Admission 95 ED_ArrDate ED Admission
NCTR-DataDictionary-22Jun2005 Table of Contents
No Datapoint Tab 96 ED_ArrTime ED Admission 97 ED_DCDate ED Admission 98 ED_DCTime ED Admission 99 ED_LOS ED Admission 100 Arriv_From ED Admission 101 Transport ED Admission 102 ChiefCom ED Admission 103 ArrivCond ED Admission 104 ED_L1Activ ED Admission 105 ED_L1ATIME ED Admission 106 ED_L1ElapT ED Admission 107 ED_L2Activ ED Admission 108 ED_L2ATime ED Admission 109 ED_L2ElapT ED Admission 110 ED_L3Activ ED Admission 111 ED_L3ATime ED Admission 112 ED_L3ElapT ED Admission 113 EDMDCode ED Admission 114 EDMDCall ED Admission 115 EDMDArriv ED Admission 116 EDMDResTim ED Admission 117 EDMDTimely ED Admission 118 TSPhCode ED Admission 119 ED_TsCall ED Admission 120 ED_TsArive ED Admission 121 TSRespTime ED Admission 122 EDTrTimely ED Admission 123 NSPhCode ED Admission 124 ED_NsCall ED Admission 125 ED_NsArriv ED Admission 126 NSRespTime ED Admission 127 EDNSTimely ED Admission 128 ORPhCode ED Admission 129 OPED_Call ED Admission 130 OPED_Arriv ED Admission 131 OSRespTime ED Admission 132 EDORTimely ED Admission 133 EDCRCode ED Admission 134 ED_CRCall ED Admission 135 ED_CRArrive ED Admission 136 ED_CRResTim ED Admission 137 ED_CRTimely ED Admission 138 EDAnCode ED Admission 139 EDAnCall ED Admission 140 EDAnArriv ED Admission 141 EDAnResTim ED Admission 142 EDAnTimely ED Admission 144 ED_Temp ED Assessment 1
NCTR-DataDictionary-22Jun2005 Table of Contents
No Datapoint Tab 145 ED_Pulse ED Assessment 1 146 ED_Resp ED Assessment 1 147 EDRe_Manaq ED Assessment 1 148 ED_BP ED Assessment 1 149 ED_Eye ED Assessment 1 150 ED_Vrb ED Assessment 1 151 ED_Mtr ED Assessment 1 152 ED_GCS ED Assessment 1 153 ED_CalcaQ ED Assessment 1 154 ED_TSArr ED Assessment 1 155 EDWCalcRTS ED Assessment 1 156 ManED_GCS ED Assessment 1 157 ED_ManaQ ED Assessment 1 158 ManED_TSArr ED Assessment 1 159 EDWManRTS ED Assessment 1 160 Airway ED Assessment 1 161 CPR ED Assessment 1 162 Blood_No ED Assessment 1 163 ETOH ED Assessment 1 164 Hct ED Assessment 1 165 BaseDef ED Assessment 1 166 Drug_Scrn ED Assessment 1 166.1 HeadCT ED Assessment 2 166.2 AssHCTDate ED Assessment 2 166.3 AssHCTTime ED Assessment 2 166.4 AbdCT ED Assessment 2 166.5 AssACTDate ED Assessment 2 166.6 AssACTTime ED Assessment 2 167 AssAbdUSou ED Assessment 2 168 AssAUSDate ED Assessment 2 169 AssAUSTime ED Assessment 2 170 AssChestCT ED Assessment 2 171 AssCCTDate ED Assessment 2 172 AssCCTTime ED Assessment 2 173 PerLav ED Assessment 2 174 AssPlvDate ED Assessment 2 175 AssPlvTime ED Assessment 2 176 AssAortoGr ED Assessment 2 177 AssAorDate ED Assessment 2 178 AssAorTime ED Assessment 2 179 AGram ED Assessment 2 180 Ass_AntDate ED Assessment 2 181 Ass_AntTime ED Assessment 2 182 ED_Disp ED Assessment 2 183 AdmService ED Assessment 2 184 AssORDisp ED Assessment 2 185 AssAdmMD ED Assessment 2 186 AssAttMD ED Assessment 2
NCTR-DataDictionary-22Jun2005 Table of Contents
No Datapoint Tab 187 ConsCode ED Assessment 2 188 ConsComme ED Assessment 2 189 ConsDate ED Assessment 2 190 ConsTime ED Assessment 2 191 DCode Diagnosis 192 AISCode Diagnosis 193 USRAIS_Abd Diagnosis 194 USRAIS_HN Diagnosis 195 USRAIS_Chs Diagnosis 196 USRAIS_Ext Diagnosis 197 USRAIS_Face Diagnosis 198 USRAIS_ST Diagnosis 199 USRAIS_ISS Diagnosis 199.1 NISS 200 MANAIS_Abd Diagnosis 201 MANAIS_Chs Diagnosis 202 MANAIS_Ext Diagnosis 203 MANAIS_Fac Diagnosis 204 ManAIS_HN Diagnosis 205 ManAIS_ST Diagnosis 206 ManAIS_ISS Diagnosis 207 ProbOfSurv Diagnosis 208 Operative Diagnosis 209 Action Comorbidity 210 ComorCode Comorbidity ComorDes 211 ComorComme Comorbidity 212 OpCode Procedures 213 OpDate Procedures 214 OpTime Procedures 215 AtPhCode Procedures 216 OpTimePstd Procedures 217 OpLocation Procedures 218 ORVisitNum Procedures 219 TCode Complications 220 Judgemt Complications 221 CompDate Complications 222 CompStatus Complications 223 CompNotes Complications 224 CompAction Complications 225 Category Complications 226 CompOcDate Complications 227 CDis_Rel Complications 228 CProv_Rel Complications 229 CSyst_Rel Complications 230 QACODE PI 231 JUDGEMENT PI 232 QADATE PI
NCTR-DataDictionary-22Jun2005 Table of Contents
No Datapoint Tab 233 STATUS PI 234 QAAction PI 235 QDis_Rel PI 236 QProv_Rel PI 237 QSyst_Rel PI 238 Notes PI 239 FIM_Feed Hospital Outcome 240 Feed_Stat Hospital Outcome 241 FIM_Indpn Hospital Outcome 242 Indpn_Stat Hospital Outcome 243 FIM_Motor Hospital Outcome 244 Motor_Stat Hospital Outcome 245 FIM_Score Hospital Outcome 246 DCDate Hospital Outcome 247 DCTime Hospital Outcome 248 HospDisp Hospital Outcome 249 Vsup_Days Hospital Outcome 250 ICUDays Hospital Outcome 251 HospDays Hospital Outcome 252 Ho23HrObs Hospital Outcome 253 HoAutopsy Hospital Outcome 254 Dth_Cause Hospital Outcome 255 HoDeathLoc Hospital Outcome 256 HospDisServ Hospital Outcome 257 OrganDonat Hospital Outcome 258 PtDirectiv Hospital Outcome 259 Res_Descr Hospital Outcome 260 DRG_Code Hospital Outcome 261 FinAcctNo Financial 262 HospChrg Financial 263 ReimbdCh Financial 264 FinalBill Financial 265 Insur Financial 266 Insur2 Financial 267 Comment Financial 268 AcctName Financial 269 Complete Financial 270 ActTotalC Financial 271 ActVarDC Financial 272 WorkRelate Financial 273 Consult1 Consult2 Consult3 Consult4 Custom Data Points 274 EDMD Custom Data Points 275 VehiclePos Custom Data Points 276 EDThorac Custom Data Points 277 EDChTube Custom Data Points
NCTR-DataDictionary-22Jun2005 Table of Contents
No Datapoint Tab 278 RefHct Custom Data Points 279 VentDays Custom Data Points 280 DCSvc Custom Data Points 281 FirstResp Custom Data Points 282 TransISS Custom Data Points 283 Level Custom Data Points 284 InptL24 Custom Data Points 285 US Custom Data Points 286 HdCTTime Custom Data Points 287 AbCTTime Custom Data Points 288 RefHspRpt Custom Data Points
NCTR-DataDictionary-22Jun2005 Demographics
No Datapoint Description of Definitions NTRACS Standard Options NC Custom Options Optional/ Download Datapoint Datapoint Required Scenario History
1 MedRecNo Listed as Patient Optional d Identifier on screen. 2 SocSecNo Patient's Social Default = blank. Required s 15 Aug 2003: Security # Changed to required field and download to State.
3 PFName Patient's first name Patient's first name
4 PMI Patient’s middle initial Patient’s middle LeaveBlank if unknown. Required s May 2002 initial Blank (Default V2.5) Change (Default V3.1). NTRACS Default from
to Blank
15 Aug 2003: Changed to required field and download to State.
5 PLName Patient’s last name Patient’s last name
NCTR-DataDictionary-22Jun2005 1 6/28/2005 Demographics
No Datapoint Description of Definitions NTRACS Standard Options NC Custom Options Optional/ Download Datapoint Datapoint Required Scenario History
6 Sex Patient’s gender
NCTR-DataDictionary-22Jun2005 2 6/28/2005 Demographics
No Datapoint Description of Definitions NTRACS Standard Options NC Custom Options Optional/ Download Datapoint Datapoint Required Scenario History
8 DOB Patient’s date of birth mm/dd/yyyy Date of birth. Required s,n 18 Oct 2000: Default = blank. If day and month of DOB are unknown, use 01/01 and year of birth so that RTS will calculate. If year unknown, leave blank (- 1).
9 Man_Age Manual entry of Patient’s age. . Optional s,n patient’s age <-1> (Default V2.5) <-4> (Default V3.1) 10 Age Patient’s age Automatically Patient’s age. Required s,n 1 May 2002: calculated by <-1> (Default V2.5) Default value NTRACS when <-4> (Default V3.1) cannot be DOB is known changed in Note: Default value can't be changed NTRACS. in NTRACS. Not available in Leave default NTRACS Edit Data Dictionary value as <-5> function. 'til NTRACS is fixed.
11 PAddress Patient’s home # and street name.
NCTR-DataDictionary-22Jun2005 3 6/28/2005 Demographics
No Datapoint Description of Definitions NTRACS Standard Options NC Custom Options Optional/ Download Datapoint Datapoint Required Scenario History
12 PAddrss2 Additional line for Blank (Default) Optional s 1 Mar 2002: patient's home New address datapoint with V3.1. 15 Aug 2003: Changed download scenario to download to State. 13 PCity Patient’s home city City name.
14 PState Patient’s state of Automatically
NCTR-DataDictionary-22Jun2005 4 6/28/2005 Demographics
No Datapoint Description of Definitions NTRACS Standard Options NC Custom Options Optional/ Download Datapoint Datapoint Required Scenario History
18 Occupation Patient’s occupation
NCTR-DataDictionary-22Jun2005 5 6/28/2005 Demographics
No Datapoint Description of Definitions NTRACS Standard Options NC Custom Options Optional/ Download Datapoint Datapoint Required Scenario History
18 Occupation Patient’s occupation 28 Jul 2004: (Continued) Expanded definition of
NCTR-DataDictionary-22Jun2005 6 6/28/2005 Injury
No Datapoint Description of Definitions NTRACS Standard Options NC Custom Options Optional/ Download Datapoint History Datapoint Required Scenario
19 InjDate Date of injury. mm/dd/yyyy Injury[sp] date. Required s,n 18 Oct 2000: Added Default = blank. Leave blank if Leave blank if date unknown. unknown to definition. 20 InjTime Time of injury Military time <[sp][sp] :-3> = Pending (V2.5) Required s,n 18 Oct 2000: Added (00:00-23:59) <[sp][sp] :-1> = Not Done/Doc Leave blank if (Default V2.5) unknown to definition. <[sp][sp] :-4> = Not Recorded (Default V3.1) 1 May 2002: Note: <[sp][sp] :-5> = Not Available Default cannot be changed in NTRACS. Changing default to :- 4 results in :-: being displayed. Leave default as :-5 'til NTRACS is fixed.
31 Jan 2005: V3.4 Default can now be changed
21 InjCity City in which injury Name of city
NCTR-DataDictionary-22Jun2005 1 6/28/2005 Injury
No Datapoint Description of Definitions NTRACS Standard Options NC Custom Options Optional/ Download Datapoint History Datapoint Required Scenario
23 InjZIP Injury Zip Code Automatically <00000> = Out of Country = 99999. Required s,n 18 Oct 2000: Out of entered by Not Done/Doc(V2.5), Country = 99999. NTRACS Not Recorded (Default V3.1) based on injcity.. 24 InjCounty County in which Automatically
25 InjCountry Country in which Automatically
NCTR-DataDictionary-22Jun2005 2 6/28/2005 Injury
No Datapoint Description of Definitions NTRACS Standard Options NC Custom Options Optional/ Download Datapoint History Datapoint Required Scenario
26 ECode Main term to <928.9> = Unspecified accident Required s,n 18 Oct 2000: For ATV describe accident: (Default) incidents use 821.0 ICD-9 E-codes (Driver), 821.1 (Passenger), 821.8 (Other specified person, such as an unauthorized rider of an off-road motor vehicle), or 821.9 (Unspecified person, off-road motor vehicle). For Moped incidents use ecode of 812.2. For Jetski incidents use ecode of 830-838 with 4th digit of 1. For Skateboard incidents use ecode of 829.8.
28 Jul 2004: For skateboard incidents stop using ecode of 829.8. V3.2 upgrade for NTRACS has a new ecode specific for skateboards and rollerblades.
NCTR-DataDictionary-22Jun2005 3 6/28/2005 Injury
No Datapoint Description of Definitions NTRACS Standard Options NC Custom Options Optional/ Download Datapoint History Datapoint Required Scenario
26.1 ECode2 Secondary term Default = Blank Required s,n 31 Jan 2005: New used to describe Leave blank if second Ecode is Data Item with V3.4 ; the incident: ICD-9 not used To be used when E-codes more than one external cause for an injury exists; same rules for Ecode Data item apply to Ecode2
27 Blunt Type of injury
NCTR-DataDictionary-22Jun2005 4 6/28/2005 Injury
No Datapoint Description of Definitions NTRACS Standard Options NC Custom Options Optional/ Download Datapoint History Datapoint Required Scenario
28 InjSite Location where
29 CrashRpt Police report Police Report number Optional s number
NCTR-DataDictionary-22Jun2005 5 6/28/2005 Injury
No Datapoint Description of Definitions NTRACS Standard Options NC Custom Options Optional/ Download Datapoint History Datapoint Required Scenario
30 Position Position of patient Automatically
1 Mar 2002: Default value changed with V3.1. Continue to use custom datapoint due to continuing incorrect autofilling of this datapoint by NTRACS.
NCTR-DataDictionary-22Jun2005 6 6/28/2005 Injury
No Datapoint Description of Definitions NTRACS Standard Options NC Custom Options Optional/ Download Datapoint History Datapoint Required Scenario
31 Safety Safety device worn <2[sp] Point[sp] Belt>: Use only
1 May 2002: Note: Default cannot be changed in NTRACS. Leave default as
28 Jul 2004: Deactivate
31 Jan 2005: V3.4 Default can now be changed
NCTR-DataDictionary-22Jun2005 7 6/28/2005 Injury
No Datapoint Description of Definitions NTRACS Standard Options NC Custom Options Optional/ Download Datapoint History Datapoint Required Scenario
31 Safety
32 InjComment Comment on Free text field Blank = Default Optional d 1 Mar 2002: New injury. datapoint with V3.1.
NCTR-DataDictionary-22Jun2005 8 6/28/2005 Pre-Hospital
No Datapoint Description of Definitions NTRACS Standard Options NC Custom Options Optional/ Download Datapoint History Datapoint Required Scenario
33 EMS EMS Service Name of Ambulance Service Use Proper Case. Required s 01 April 2005 used (Provider
34 AmbRun Ambulance
NCTR-DataDictionary-22Jun2005 1 6/28/2005 Pre-Hospital
No Datapoint Description of Definitions NTRACS Standard Options NC Custom Options Optional/ Download Datapoint History Datapoint Required Scenario
35 ScEMSRpt Scene EMS Is the EMS report on
36 Sconditn Condition of
NCTR-DataDictionary-22Jun2005 2 6/28/2005 Pre-Hospital
No Datapoint Description of Definitions NTRACS Standard Options NC Custom Options Optional/ Download Datapoint History Datapoint Required Scenario
37 DispDate Dispatch date mm/dd/yyyy Default = blank Required s,n 18 Oct 2000: of EMS: Date if EMS Clarified field that unit was Report not description: notified by missing. Dispdate = date unit EMD/Dispatch, was notified by which is the dispatch. 911 call date (or the day after, if the call occurred near midnight).
38 DispTime Dispatch time Military time (00:00- <[sp][sp] :-3> = Pending (V2.5) Required s,n 18 Oct 2000: of EMS: This is 23:59) <[sp][sp] :-1> = Not Done/Doc if EMS Clarified field the Notified by (Default V2.5) Report not description: Use the Dispatch time <[sp][sp] :-4> = Not Recorded missing. time the unit was on the PreMIS (Default V3.1) notified by dispatch. form. <[sp][sp] :-5> = Not Available 1 May 2002: Note: Default cannot be changed in NTRACS. Changing default to :-4 results in :-: being displayed. Leave default as :-5 'til NTRACS is fixed.
31 Jan 2005: V3.4 Default can now be changed
NCTR-DataDictionary-22Jun2005 3 6/28/2005 Pre-Hospital
No Datapoint Description of Definitions NTRACS Standard Options NC Custom Options Optional/ Download Datapoint History Datapoint Required Scenario
39 ArrTime Arrival time of Military time (00:00- <[sp][sp] :-3> = Pending (V2.5) Required s,n 18 Oct 2000: Added EMS at injury 23:59) <[sp][sp] :-1> = Not Done/Doc if EMS PreMIS field name to scene. This is (Default V2.5) Report not field description. the On-Scene <[sp][sp] :-4> = Not Recorded missing. time on the (Default V3.1) 1 May 2002: Note: PreMIS form. <[sp][sp] :-5> = Not Available Default cannot be changed in NTRACS. Changing default to :-4 results in :-: being displayed. Leave default as :-5 'til NTRACS is fixed.
31 Jan 2005: V3.4 Default can now be changed
40 SceneTime Total number Automatically calculated by Required s,n 1 May 2002: Note: of minutes NTRACS. if EMS Default cannot be spent at the <-5> = Not Available (Default V3.1) Report not changed in scene by EMS missing. NTRACS. Not Note: Default value can't be available in changed in NTRACS. Not available NTRACS Edit Data in NTRACS Edit Data Dictionary Dictionary function. function. Leave default as :-5 'til NTRACS is fixed.
NCTR-DataDictionary-22Jun2005 4 6/28/2005 Pre-Hospital
No Datapoint Description of Definitions NTRACS Standard Options NC Custom Options Optional/ Download Datapoint History Datapoint Required Scenario
41 DeptTime Departure time Military time (00:00- <[sp][sp] :-3> = Pending (V2.5) Required s,n 18 Oct 2000: Added of EMS: Time 23:59) <[sp][sp] :-1> = Not Done/Doc if EMS PreMIS field name to EMS left (Default V2.5) Report not field description. scene. This is <[sp][sp] :-4> = Not Recorded missing. the Left Scene (Default V3.1) 1 May 2002: Note: time on the <[sp][sp] :-5> = Not Available Default cannot be PreMIS form. changed in NTRACS. Changing default to :-4 results in :-: being displayed. Leave default as :-5 'til NTRACS is fixed.
31 Jan 2004: V3.4 Default can now be changed
42 TranspTime Transport time Automatically calculated by Required s,n 1 May 2002: Note: of EMS NTRACS. if EMS Default cannot be <-5> = Not Available (Default V3.1) Report not changed in missing. NTRACS. Not Note: Default value can't be available in changed in NTRACS. Not available NTRACS Edit Data in NTRACS Edit Data Dictionary function. Leave function. default as :-5 'til NTRACS is fixed.
NCTR-DataDictionary-22Jun2005 5 6/28/2005 Pre-Hospital
No Datapoint Description of Definitions NTRACS Standard Options NC Custom Options Optional/ Download Datapoint History Datapoint Required Scenario
43 ArrHosp1 Arrival time at Military time (00:00- <[sp][sp] :-3> = Pending (V2.5) Required s,n 18 Oct 2000: Added referring 23:59) <[sp][sp] :-1> = Not Done/Doc if EMS PreMIS field name to hospital. This (Default V2.5) Report not field description. is the At <[sp][sp] :-4> = Not Recorded missing. Destination (Default V3.1) 1 May 2002: Note: time on the <[sp][sp] :-5> = Not Available Default cannot be PreMIS form. changed in NTRACS. Changing default to :-4 results in :-: being displayed. Leave default as :-5 'til NTRACS is fixed.
31 Jan 2005: V3.4 Default can now be changed
44 Spulse Initial pulse Pulse rate in beats <-3> = Pending (V2.5) Required s,n 18 Oct 2000: rate at the per minute <-1> = Not Done/Doc (Default V2.5) if EMS Changed definition scene <-4> = Not Recorded (Default V3.1) Report not to reflect recording <-5> = Not Available missing. of initial value only.
45 SResp Initial Breaths per minute <-3> = Pending (V2.5) Required s,n 18 Oct 2000: respiratory rate <-1> = Not Done/Doc (Default V2.5) if EMS Changed definition at the scene <-4> = Not Recorded (Default V3.1) Report not to reflect recording <-5> = Not Available missing. of initial value only.
NCTR-DataDictionary-22Jun2005 6 6/28/2005 Pre-Hospital
No Datapoint Description of Definitions NTRACS Standard Options NC Custom Options Optional/ Download Datapoint History Datapoint Required Scenario
46 SBP Initial systolic Acceptable range=0- <-3> = Pending (V2.5) Required s,n 18 Oct 2000: blood pressure 300. <-1> = Not Done/Doc (Default V2.5) if EMS Changed definition at the scene <-4> = Not Recorded (Default V3.1) Report not to reflect recording <-5> = Not Available missing. of initial value only.
47 Seye Eye score on <1> = Does not open eyes Required s,n 18 Oct 2000: Added initial GCS at <2> = Opens eyes to pain if EMS initial to datapoint the scene <3> = Opens eyes to commands Report not description. <4> = Spontaneous eye opening missing. <-1> = Not Done/Doc (Default V2.5) <-3> = Pending (V2.5) <-4> = Not Recorded (Default V3.1) <-5> = Not Available <-6> = Not Performed
48 SVrb Verbal <1> = No response Required s,n 18 Oct 2000: Added response on <2> = Incomprehensible sounds if EMS initial to datapoint initial GCS at <3> = Inappropriate words Report not description. the scene <4> = Disoriented and converses missing. <5> = Oriented and converses <-1> = Not Done/Doc (Default V2.5) <-3> = Pending (V2.5) <-4> = Not Recorded (Default V3.1) <-5> = Not Available <-6> = Not Performed
NCTR-DataDictionary-22Jun2005 7 6/28/2005 Pre-Hospital
No Datapoint Description of Definitions NTRACS Standard Options NC Custom Options Optional/ Download Datapoint History Datapoint Required Scenario
49 SMtr Motor <1> = No response Required s,n 18 Oct 2000: Added response on <2> = Extends to pain if EMS initial to datapoint initial GCS at <3> = Flexes to pain Report not description. the scene <4> = Moves to pain missing. <5> = Localizes pain <6> = Follows commands <-1> = Not Done/Doc (Default V2.5) <-3> = Pending (V2.5) <-4> = Not Recorded (Default V3.1) <-5> = Not Available <-6> = Not Performed
50 SGCS Glasgow Coma Automatically Range 3-15. Required s,n 1 May 2002: Note: Score at the calculated by <-1> = Not Done/Doc (Default V2.5) if EMS Default cannot be scene NTRACS <-3> = Pending (V2.5) Report not changed in <-4> = Not Recorded (Default V3.1) missing. NTRACS. Not <-5> = Not Available available in NTRACS Edit Data Note: Default value can't be Dictionary function. changed in NTRACS. Not available Leave default as -5 in NTRACS Edit Data Dictionary 'til NTRACS is fixed. function.
NCTR-DataDictionary-22Jun2005 8 6/28/2005 Pre-Hospital
No Datapoint Description of Definitions NTRACS Standard Options NC Custom Options Optional/ Download Datapoint History Datapoint Required Scenario
51 STS Revised Automatically If values of the GCS, BP or Required s,n 1 May 2002: Note: Trauma Score calculated by Respiratory Rate are missing: if EMS Default cannot be at the Scene NTRACS. <-1> = Not Done/Doc (Default V2.5) Report not changed in Based on the values <-4> = Not Recorded (Default V3.1) missing. NTRACS. Not of the GCS, systolic <-5> = Not Available available in BP, and Respiratory NTRACS Edit Data Rate Note: Default value can't be Dictionary functioin. changed in NTRACS. Not available Leave default as -5 in NTRACS Edit Data Dictionary 'til NTRACS is fixed. function.
52 Pre_CalcAQ Assessment = Chemically sedated componen value of L because scene.
NCTR-DataDictionary-22Jun2005 9 6/28/2005 Pre-Hospital
No Datapoint Description of Definitions NTRACS Standard Options NC Custom Options Optional/ Download Datapoint History Datapoint Required Scenario
53 Man_SGCS Manual This field is used Range 3-15. Optional s,n 18 Oct 2000: Glasgow Coma when eye, verbal, <-1> = Not Done/Doc (Default V2.5) Completion of this Score at the and motor values are <-3> = Pending (V2.5) field is optional. scene not available, but <-4> = Not Recorded (Default V3.1) GCS is manually <-5> = Not Available calculated.
54 Man_STS Manual First recorded RTS at If values of the GCS, BP or Optional s,n 18 Oct 2000: Revised the scene. Respiratory Rate are missing: Completion of this Trauma Score Use when any of the <-1> = Default (V2.5) field is optional. at the scene 3 components of the <-4> = Not Recorded (Default V3.1) RTS are Not <-5> = Not Available Done/Doc. 55 Pre_Manaq Assessment = Chemically sedated if Man_sgcs is given
NCTR-DataDictionary-22Jun2005 10 6/28/2005 Pre-Hospital
No Datapoint Description of Definitions NTRACS Standard Options NC Custom Options Optional/ Download Datapoint History Datapoint Required Scenario
56 Pre-CPR CPR
NCTR-DataDictionary-22Jun2005 11 6/28/2005 Pre-Hospital
No Datapoint Description of Definitions NTRACS Standard Options NC Custom Options Optional/ Download Datapoint History Datapoint Required Scenario
57 Pre_Airway Airway
6 Mar 2002: Removed
NCTR-DataDictionary-22Jun2005 12 6/28/2005 Pre-Hospital
No Datapoint Description of Definitions NTRACS Standard Options NC Custom Options Optional/ Download Datapoint History Datapoint Required Scenario
58 Pre_Mast MAST Military Anti-Shock
59 Pre_Fluid Fluid Crystalloid only. DO <<500> = Less than 500 ml Required s,n 18 Oct 2000:
NCTR-DataDictionary-22Jun2005 13 6/28/2005 Pre-Hospital
No Datapoint Description of Definitions NTRACS Standard Options NC Custom Options Optional/ Download Datapoint History Datapoint Required Scenario
60 PreNeedlTh Pre-hospital A procedure that
61 PreTubeTho Pre-hospital To remove blood or
NCTR-DataDictionary-22Jun2005 14 6/28/2005 Pre-Hospital
No Datapoint Description of Definitions NTRACS Standard Options NC Custom Options Optional/ Download Datapoint History Datapoint Required Scenario
62 PreDrug Prehospital Multi-entry
31 Jan 2005: It appears as if the default can now be changed, but in reality changing it does not effect a change in the default value when adding a new patient into the registry
NCTR-DataDictionary-22Jun2005 15 6/28/2005 Referring Hospital
No Datapoint Description of Definitions NTRACS Standard NC Custom Options Optional/R Download Datapoint History Datapoint Options equired Scenario
63 HospTrf Hospital transfer = Pending (V2.5) 65 Ref_ArrTim Arrival time at referring Military time (00:00- <[sp][sp] :-3> = Pending Required if s,n 1 May 2002: Note: hospital 23:59) (V2.5) Referring Default cannot be <[sp][sp] :-1> = Not Hospital changed in Done/Doc (Default V2.5) report not NTRACS. <[sp][sp] :-4> = Not missing (per Changing default to Recorded (Default V3.1) custom :-4 results in :-: <[sp][sp] :-5> = Not datapoint being displayed. Available RefHspRpt) Leave default as :-5 'til NTRACS is fixed. 31 Jan 2005 Default can now be changed NCTR-DataDictionary-22Jun2005 1 6/28/2005 Referring Hospital No Datapoint Description of Definitions NTRACS Standard NC Custom Options Optional/R Download Datapoint History Datapoint Options equired Scenario 66 Ref_DCDate Discharge date from mm/dd/yyyy Default = blank. Required if s,n referring hospital Referring Hospital report not missing (per custom datapoint RefHspRpt) 67 Ref_DCTime Discharge time from Military time (00:00- <[sp][sp] :-3> = Pending Required if s,n 1 May 2002: Note: referring hospital 23:59) (V2.5) Referring Default cannot be <[sp][sp] :-1> = Not Hospital changed in Done/Doc (Default V2.5) report not NTRACS. <[sp][sp] :-4> = Not missing (per Changing default to Recorded (Default V3.1) custom :-4 results in :-: <[sp][sp] :-5> = Not datapoint being displayed. Available RefHspRpt) Leave default as :-5 'til NTRACS is fixed. 31 Jan 2005 Default can now be changed 68 ReferHosp Referring hospital Name of Referring Required s 18 Oct 2000: Hospital Statewide standard NCTR-DataDictionary-22Jun2005 2 6/28/2005 Referring Hospital No Datapoint Description of Definitions NTRACS Standard NC Custom Options Optional/R Download Datapoint History Datapoint Options equired Scenario 69 Ref_MD Referring physician Name of referring Optional d name physician 71 Ref_Resp Initial respiratory rate Spontaneous, <-3> = Pending (V2.5) Required if s,n 18 Oct 2000: Added at referring hospital unassisted breaths <-1> = Not Done/Doc Referring initial to datapoint per minute. Enter 0 if (Default V2.5) Hospital description. Added intubated or bagged. <-4> = Not Recorded report not Enter 0 if intubated (Default V3.1) missing (per or bagged to <-5> = Not Available custom definition so RTS datapoint will calculate.. RefHspRpt) NCTR-DataDictionary-22Jun2005 3 6/28/2005 Referring Hospital No Datapoint Description of Definitions NTRACS Standard NC Custom Options Optional/R Download Datapoint History Datapoint Options equired Scenario 72 Ref_BP Initial systolic blood <-3> = Pending (V2.5) Required if s,n 18 Oct 2000: Added pressure at referring <-1> = Not Done/Doc Referring initial to datapoint hospital (Default V2.5) Hospital description. <-4> = Not Recorded report not (Default V3.1) missing (per <-5> = Not Available custom datapoint RefHspRpt) 73 Ref_Eye Initial eye score on <1> = Does not open Required if s,n 18 Oct 2000: Added GCS at the referring eyes Referring initial to datapoint hospital <2> = Opens eyes to Hospital description. pain report not <3> = Opens eyes to missing (per commands custom <4> = Spontaneous eye datapoint opening RefHspRpt) <-1> = Not Done/Doc (Default V2.5) <-3> = Pending (V2.5) <-4> = Not Recorded (Default V3.0) <-5> = Not Available <-6> = Not Performed NCTR-DataDictionary-22Jun2005 4 6/28/2005 Referring Hospital No Datapoint Description of Definitions NTRACS Standard NC Custom Options Optional/R Download Datapoint History Datapoint Options equired Scenario 74 Ref_Vrb Initial verbal response <1> = No response Required if s,n 18 Oct 2000: Added on GCS at the <2> = Incomprehensible Referring initial to datapoint referring hospital sounds Hospital description. <3> = Inappropriate report not words missing (per <4> = Disoriented and custom converses datapoint <5> = Oriented and RefHspRpt) converses <-1> = Not Done/Doc (Default V2.5) <-3> = Pending (V2.5) <-4> = Not Recorded (Default V3.1) <-5> = Not Available <-6> = Not Performed 75 Ref_Mtr Initial motor response <1> = No response Required if s,n 18 Oct 2000: Added on GCS at the <2> = Extends to pain Referring initial to datapoint referring hospital <3> = Flexes to pain Hospital description. <4> = Moves to pain report not <5> = Localizes pain missing (per <6> = Follows custom commands datapoint <-1> = Not Done/Doc RefHspRpt) (Default V2.5) <-3> = Pending (V2.5) <-4> = Not Recorded (Default V3.1) <-5> = Not Available <-6> = Not Performed NCTR-DataDictionary-22Jun2005 5 6/28/2005 Referring Hospital No Datapoint Description of Definitions NTRACS Standard NC Custom Options Optional/R Download Datapoint History Datapoint Options equired Scenario 76 Ref_GCS Initial Glasgow Coma Automatically <-1> = Not Done/Doc Required if s,n 18 Oct 2000: Added Score at referring calculated by (Default V2.5) Referring initial to datapoint hospital NTRACS. <-3> = Pending (V2.5) Hospital description. <-4> = Not Recorded report not (Default V3.1) missing (per 1 May 2002: Note: <-5> = Not Available custom Default cannot be datapoint changed in Note: Default value can't RefHspRpt) NTRACS. Leave be changed in NTRACS. default as <-5> 'til Not available in NTRACS NTRACS is fixed. Edit Data Dictionary function. 77 REF_TS Revised Trauma Automatically If values of the GCS, BP Required if s,n 1 May 2002: Note: Score at the referring calculated by or Respiratory Rate are Referring Default cannot be hospital NTRACS. missing: Hospital changed in Based on the values <-1> = Not Done/Doc report not NTRACS. Leave of the GCS, systolic (Default V2.5) missing (per default as <-5> 'til BP, and Respiratory <-4> = Not Recorded custom NTRACS is fixed. Rate (Default V3.1) datapoint <-5> = Not Availabe RefHspRpt) Note: Default value can't be changed in NTRACS. Not available in NTRACS Edit Data Dictionary function. NCTR-DataDictionary-22Jun2005 6 6/28/2005 Referring Hospital No Datapoint Description of Definitions NTRACS Standard NC Custom Options Optional/R Download Datapoint History Datapoint Options equired Scenario 78 Ref_CalcAQ Assessment Qualifier 79 ManRef_GCS Manual Glasgow Use when any of 3 <-1> Not Done/Doc 18 Jul 2001: s,n 18 Jul 2000: Use coma Score at the components of (Default V2.5) Optional this field if GCS referring hospital ref_gcs is missing. <-4> Not Recorded components are not (Default V3.1) documented, but <-5> Not Available total GCS is documented. Note: Default value cannot be changed in 1 May 2002: Note: NTRACS. Default cannot be changed in NTRACS. Leave default as <-5> 'til NTRACS is fixed. NCTR-DataDictionary-22Jun2005 7 6/28/2005 Referring Hospital No Datapoint Description of Definitions NTRACS Standard NC Custom Options Optional/R Download Datapoint History Datapoint Options equired Scenario 80 ManRef_TS Manual Revised Use when any of the If values of the GCS, BP 18 Jul 2001: s,n 18 Jul 2000: Use Trauma Score at the 3 components of the or Respiratory Rate are Optional this field if TS referring hospital RTS is missing. missing: components are not <-1> Not Done/Doc documented, but TS (Default V2.5) is documented. <-4> Not Recorded (Default V3.1) <-5> Not Available 81 Ref_ManAQ Assessment Qualifier NCTR-DataDictionary-22Jun2005 8 6/28/2005 Referring Hospital No Datapoint Description of Definitions NTRACS Standard NC Custom Options Optional/R Download Datapoint History Datapoint Options equired Scenario 82 RefHeadCT Results of Head CT at Results from reading 83 RefChestCT Results of Chest CT at Results from reading NCTR-DataDictionary-22Jun2005 9 6/28/2005 Referring Hospital No Datapoint Description of Definitions NTRACS Standard NC Custom Options Optional/R Download Datapoint History Datapoint Options equired Scenario 84 RefPerLav Results of Peritoneal Results from reading 85 RefAorto Results of Aortogram Results from reading 86 RefArterio Results of Arteriogram Results from reading NCTR-DataDictionary-22Jun2005 10 6/28/2005 Referring Hospital No Datapoint Description of Definitions NTRACS Standard NC Custom Options Optional/R Download Datapoint History Datapoint Options equired Scenario 87 RefAbdUlso Results of abdominal Results from reading 88 RefAbdCT Results of Abdominal Results from reading NCTR-DataDictionary-22Jun2005 11 6/28/2005 Referring Hospital No Datapoint Description of Definitions NTRACS Standard NC Custom Options Optional/R Download Datapoint History Datapoint Options equired Scenario 89 RefAirway Airway inserted at NCTR-DataDictionary-22Jun2005 12 6/28/2005 Referring Hospital No Datapoint Description of Definitions NTRACS Standard NC Custom Options Optional/R Download Datapoint History Datapoint Options equired Scenario 93 RefDrug Drugs given at Multi-entry from pick- 01Jan2005: Default may now be changed NCTR-DataDictionary-22Jun2005 13 6/28/2005 ED Admission No Datapoint Description of Definitions NTRACS Standard NC Custom Options Optional/R Download Datapoint Datapoint Options equired Scenario History 94 Dir_Admit Direct admission Admission to your = Pending (V2.5) Required s,n hospital without NCTR-DataDictionary-22Jun2005 1 6/28/2005 ED Admission No Datapoint Description of Definitions NTRACS Standard NC Custom Options Optional/R Download Datapoint Datapoint Options equired Scenario History 96 ED_ArrTime ED arrival time (First Military time (00:00-<[sp][sp] :-3> = Pending Required s,n 18 Oct 2000: time of intervention, 23:59) (V2.5) Added to treatment, or vital <[sp][sp] :-1> = Not definition: first signs) Done/Doc (Default V2.5) time of <[sp][sp] :-4> = Not occurrence of any Recorded (Default V3.1) of the following: <[sp][sp] :-5> = Not intervention, Available treatment, or vital signs. 1 May 2002: Note: Default cannot be changed in NTRACS. Changing default to :-4 results in :-: being displayed. Leave default as :- 5 'til NTRACS is fixed. 31 Jan 2005 Default can now be changed 97 ED_DCDate Discharge date from mm/dd/yyyy Default = blank. Required s,n ED NCTR-DataDictionary-22Jun2005 2 6/28/2005 ED Admission No Datapoint Description of Definitions NTRACS Standard NC Custom Options Optional/R Download Datapoint Datapoint Options equired Scenario History 98 ED_DCTime Discharge time from Military time (00:00-<[sp][sp] :-3> = Pending Required s,n 1 May 2002: ED 23:59) (V2.5) Note: Default <[sp][sp] :-1> = Not cannot be Done/Doc (Default V2.5) changed in <[sp][sp] :-4> = Not NTRACS. Recorded (Default V3.1) Changing default <[sp][sp] :-5> = Not to :-4 results in :-: Available being displayed. Leave default as :- 5 'til NTRACS is fixed. 31 Jan 2005 Default can now be changed 99 ED_LOS ED Length of Stay Autocalculated <[sp][sp] :-3> = Pending Required s,n (V2.5) <[sp][sp] :-1> = Not Done/Doc (Default V2.5) <[sp][sp] :-4> = Not Recorded (Default V3.1) <[sp][sp ]:-5> = Not Available Note: Default value cannot be changed in NTRACS. NCTR-DataDictionary-22Jun2005 3 6/28/2005 ED Admission No Datapoint Description of Definitions NTRACS Standard NC Custom Options Optional/R Download Datapoint Datapoint Options equired Scenario History 100 Arriv_From Arrived from 101 Transport Mode of transport NCTR-DataDictionary-22Jun2005 4 6/28/2005 ED Admission No Datapoint Description of Definitions NTRACS Standard NC Custom Options Optional/R Download Datapoint Datapoint Options equired Scenario History 102 ChiefComp Worst chief complaint NCTR-DataDictionary-22Jun2005 5 6/28/2005 ED Admission No Datapoint Description of Definitions NTRACS Standard NC Custom Options Optional/R Download Datapoint Datapoint Options equired Scenario History 102 ChiefComp Worst chief complaint NCTR-DataDictionary-22Jun2005 6 6/28/2005 ED Admission No Datapoint Description of Definitions NTRACS Standard NC Custom Options Optional/R Download Datapoint Datapoint Options equired Scenario History 103 ArrivCond Arrival condition 104 ED_L1Activ Was a Level 1 trauma Y/N = Pending (V2.5) NCTR-DataDictionary-22Jun2005 7 6/28/2005 ED Admission No Datapoint Description of Definitions NTRACS Standard NC Custom Options Optional/R Download Datapoint Datapoint Options equired Scenario History 105 ED_L1ATIME Time of activation of Military time (00:00-<[sp][sp] :-3> = Pending Required if s,n 1 May 2002: Level 1 trauma team 23:59) (V2.5) Level 1 Note: Default <[sp][sp] :-1> = Not trauma cannot be Done/Doc (Default V2.5) team changed in <[sp][sp] :-4> = Not activated. NTRACS. Recorded (Default V3.1) Changing default <[sp][sp] :-5> = Not to :-4 results in :-: Available being displayed. Leave default as :- 5 'til NTRACS is fixed. 01Jan2005: Default appears to be changed, but if tab past the field it converts to - 5 106 ED_L1ElapT Trauma Team Level 1 Autogenerated. <-5> = Not Available Required if s,n 1 May 2002: elapsed time (minutes) No value unless Level 1 Note: Default Team activated. Note: Default value cannot trauma cannot be be changed in NTRACS. team changed in activated. NTRACS. 107 ED_L2Activ Was a Level 2 trauma = Pending (V2.5) activation. NCTR-DataDictionary-22Jun2005 8 6/28/2005 ED Admission No Datapoint Description of Definitions NTRACS Standard NC Custom Options Optional/R Download Datapoint Datapoint Options equired Scenario History 108 ED_L2ATime Time of activation of Military time (00:00-<[sp][sp] :-3> = Pending Required if s,n 6 Mar 2002: Level 2 trauma team 23:59) (V2.5) Level 2 Delete Pending <[sp][sp] :-1> = Not trauma from list. Done/Doc (Default V2.5) team <[sp][sp] :-4> = Not activated. 1 May 2002: Recorded (Default V3.1) Note: Default <[sp][sp] :-5> = Not cannot be Available changed in NTRACS. Note: Default value cannot Changing default be changed in NTRACS. to :-4 results in :-: being displayed. Leave default as :- 5 'til NTRACS is fixed. 01Jan2005: Default appears to be changed, but if tab past the field it converts to - 5 109 ED_L2ElapT Trauma Team Level 2 Autogenerated. <-5> = Not Available Required if s,n 1 May 2002: elapsed time (minutes) No value unless Level 2 Note: Default Team activated. Note: Default value cannot trauma cannot be be changed in NTRACS. team changed in activated. NTRACS. 110 ED_L3Activ Was a Level 3 trauma NCTR-DataDictionary-22Jun2005 9 6/28/2005 ED Admission No Datapoint Description of Definitions NTRACS Standard NC Custom Options Optional/R Download Datapoint Datapoint Options equired Scenario History 111 ED_L3ATime Time of activation of Military time (00:00-<[sp][sp] :-4> = Not Required if s,n 1 Mar 2002: New Level 3 trauma team 23:59) Recorded (Default V3.1) Level 3 datapoint with <[sp][sp] :-5> = Not trauma V3.1. Available team activated. 1 May 2002: Note: Default value cannot Note: Default be changed in NTRACS. cannot be changed in NTRACS. Changing default to :-4 results in :-: being displayed. Leave default as :- 5 'til NTRACS is fixed. 01Jan2005: Default appears to be changed, but if tab past the field it converts to - 5 112 ED_L3ElapT Trauma Team Level 3 Autogenerated. <-4> = Not Recorded Required if s,n 1 Mar 2002: New elapsed time (minutes) No value unless (Default V3.1) Level 3 datapoint with Team activated. <-5> = Not Available trauma V3.1. team activated. 1 May 2002: Note: Default cannot be changed in NTRACS. NCTR-DataDictionary-22Jun2005 10 6/28/2005 ED Admission No Datapoint Description of Definitions NTRACS Standard NC Custom Options Optional/R Download Datapoint Datapoint Options equired Scenario History 113 EDMDCode Emergency medicine User defined. Optional d 1 Mar 2002: New physician code datapoint with Default value cannot be V3.1. Replaces defined in NTRACS. NC Custom datapoint: EDMD. 1 May 2002: Note: Default cannot be changed in NTRACS. 01Jan2005: Default appears to be changed, but it does not work properly NCTR-DataDictionary-22Jun2005 11 6/28/2005 ED Admission No Datapoint Description of Definitions NTRACS Standard NC Custom Options Optional/R Download Datapoint Datapoint Options equired Scenario History 114 EDMDCall TIme emergency Military time (00:00-<[sp][sp] :-3> = Pending Required if s 1 Mar 2002: New medicine physician 23:59) (V2.5) emergency datapoint with called. <[sp][sp] :-1> = Not physician V3.1. Done/Doc (Default V2.5) called. <[sp][sp] :-4> = Not 1 May 2002: Recorded (Default V3.1) Note: Default <[sp][sp] :-5> = Not cannot be Available changed in NTRACS. Changing default to :-4 results in :-: being displayed. Leave default as :- 5 'til NTRACS is fixed. 01Jan2005: Defaults can now be changed in NTRACS NCTR-DataDictionary-22Jun2005 12 6/28/2005 ED Admission No Datapoint Description of Definitions NTRACS Standard NC Custom Options Optional/R Download Datapoint Datapoint Options equired Scenario History 115 EDMDArriv Time emergency Military time (00:00-<[sp][sp] :-3> = Pending Required if s 1 Mar 2002: New medicine physician 23:59) (V2.5) emergency datapoint with arrived in the ED <[sp][sp] :-1> = Not physician V3.1. (physical presence). Done/Doc (Default V2.5) called. <[sp][sp] :-4> = Not 1 May 2002: Recorded (Default V3.1) Note: Default <[sp][sp] :-5> = Not cannot be Available changed in NTRACS. Changing default to :-4 results in :-: being displayed. Leave default as :- 5 'til NTRACS is fixed. 01 Jan 2005: Defaults can be changed now 116 EDMDResTim Emergency medicine # of minutes Required if s 1 Mar 2002: New physician response [Automatically calculated] emergency datapoint with time <-4> = Not Recorded physician V3.1. (Default) called. <-5> = Not Available 117 EDMDTimely Emergency medicine "Timely" defined by NCTR-DataDictionary-22Jun2005 13 6/28/2005 ED Admission No Datapoint Description of Definitions NTRACS Standard NC Custom Options Optional/R Download Datapoint Datapoint Options equired Scenario History 118 TSPhCode Trauma surgeon User defined. Optional d 1 May 2002: physician code Note: Default Default value cannot be cannot be defined in NTRACS. changed in NTRACS. 01Jan2005: Default appears to be changed, but it does not work properly 119 ED_TsCall Time trauma surgeon Military time (00:00-<[sp][sp] :-3> = Pending Required if s,n 18 Oct 2000: called, ie, the time the 23:59) (V2.5) trauma Added ie, the call to the pager is <[sp][sp] :-1> = Not team time the call to completed. Done/Doc (Default V2.5) activated. the pager is <[sp][sp] :-4> = Not completed to the Recorded (Default V3.1) description. <[sp][sp] :-5> = Not Available 1 May 2002: Note: Default cannot be changed in NTRACS. Changing default to :-4 results in :-: being displayed. Leave default as :- 5 'til NTRACS is fixed. 01 Jan 2005: Degaults can now be changed NCTR-DataDictionary-22Jun2005 14 6/28/2005 ED Admission No Datapoint Description of Definitions NTRACS Standard NC Custom Options Optional/R Download Datapoint Datapoint Options equired Scenario History 120 ED_TsArive Time trauma surgeon Military time (00:00-<[sp][sp]:-3> = Pending Required if s,n 18 Oct 2000: arrived in the ED or at 23:59) (V2.5) trauma Added physical patient’s side (physical <[sp][sp]:-1> = Not team presence to presence). Done/Doc (Default V2.5) activated. description. <[sp][sp]:-4> = Not Recorded (Default V3.1) 1 May 2002: <[sp][sp]:-5> = Not Note: Default Available cannot be changed in Note: Default value cannot NTRACS. be changed in NTRACS. Changing default to :-4 results in :-: being displayed. Leave default as :- 5 'til NTRACS is fixed. 121 TSRespTime Trauma surgeon Autogenerated. <-1> = Not Done/Doc Required if s,n 1 May 2002: response time No value unless (Default V2.5) trauma Note: Default Team activated. <-4> = Not Recorded team cannot be (Default V3.1) activated. changed in <-5> = Not Available NTRACS. Note: Default value cannot be changed in NTRACS. 122 EDTrTimely Trauma Surgeon "Timely" defined by NCTR-DataDictionary-22Jun2005 15 6/28/2005 ED Admission No Datapoint Description of Definitions NTRACS Standard NC Custom Options Optional/R Download Datapoint Datapoint Options equired Scenario History 123 NSPhCode Neuro surgeon User defined. Optional d 1 May 2002: physician code Note: Default Default value cannot be cannot be defined in NTRACS. changed in NTRACS. 124 ED_NsCall Time Neuro surgeon Military time (00:00-<[sp][sp] :-3> = Pending Required if s,n 25 Sep 2000: called 23:59) (V2.5) Neurosurge Request emailed <[sp][sp] :-1> = Not ry called. to HG and KVM at Done/Doc (Default V2.5) NTRACS to add <[sp][sp] :-4> = Not Not Performed as Recorded (Default V3.1) an option. <[sp][sp] -5> = Not Available 1 May 2002: Note: Default cannot be changed in NTRACS. Changing default to :-4 results in :-: being displayed. Leave default as :- 5 'til NTRACS is fixed. 01Jan 2005: Defaults can be changed now NCTR-DataDictionary-22Jun2005 16 6/28/2005 ED Admission No Datapoint Description of Definitions NTRACS Standard NC Custom Options Optional/R Download Datapoint Datapoint Options equired Scenario History 125 ED_NsArriv Time Neuro surgeon Military time (00:00-<[sp][sp]:-3> = Pending Required if s,n 25 Sep 2000: arrived in the ED 23:59) (V2.5) Neurosurge Request emailed (physical presence). <[sp][sp]:-1> = Not ry called. to HG and KVM at Done/Doc (Default V2.5) NTRACS to add <[sp][sp]:-4> = Not Not Performed as Recorded (Default V3.1) an option. <[sp][sp]:-5> = Not Available Do not use consult time unless consult was done in ED. 1 May 2002: Note: Default cannot be changed in NTRACS. Changing default to :-4 results in :-: being displayed. Leave default as :- 5 'til NTRACS is fixed. 01 Jan 2005: Defaults can be changed now NCTR-DataDictionary-22Jun2005 17 6/28/2005 ED Admission No Datapoint Description of Definitions NTRACS Standard NC Custom Options Optional/R Download Datapoint Datapoint Options equired Scenario History 126 NSRespTime Neuro surgeon Autogenerated. <-1> = Not Done/Doc Required if s,n 25 Sep 2000: response time No value unless (Default V2.5) Neurosurge Request emailed Team activated. <-4> = Not Recorded ry called. to HG and KVM at (Default V3.1) NTRACS to add <-5> = Not Available Not Performed as an option. Note: Default value cannot be changed in NTRACS. 1 May 2002: Note: Default cannot be changed in NTRACS. 127 EDNSTimely Neurosurgeon arrival "Timely" defined by NCTR-DataDictionary-22Jun2005 18 6/28/2005 ED Admission No Datapoint Description of Definitions NTRACS Standard NC Custom Options Optional/R Download Datapoint Datapoint Options equired Scenario History 129 OPED_Call Time orthopedic Military time (00:00-<[sp][sp] :-3> = Pending Required if s,n 25 Sep 2000: surgeon called 23:59) (V2.5) Orthopedic Request emailed <[sp][sp] :-1> = Not s called. to HG and KVM at Done/Doc (Default V2.5) NTRACS to add <[sp][sp] :-4> = Not Not Performed as Recorded (Default V3.1) an option. <[sp][sp] :-5> = Not Available 1 May 2002: Note: Default cannot be changed in NTRACS. Changing default to :-4 results in :-: being displayed. Leave default as :- 5 'til NTRACS is fixed. 01Jan 2005: Defaults can be changed now NCTR-DataDictionary-22Jun2005 19 6/28/2005 ED Admission No Datapoint Description of Definitions NTRACS Standard NC Custom Options Optional/R Download Datapoint Datapoint Options equired Scenario History 130 OPED_Arriv Time orthopedic Military time (00:00-<[sp][sp] :-3> = Pending Required if s,n 25 Sep 2000: surgeon arrived in the 23:59) (V2.5) Orthopedic Request emailed ED (physical <[sp][sp] :-1> = Not s called. to HG and KVM at presence). Done/Doc (Default V2.5) NTRACS to add <[sp][sp] :-4> = Not Not Performed as Recorded (Default V3.1) an option. Do not <[sp][sp] :-5> = Not use consult time Available unless consult was done in ED. Note: Default value cannot be changed in NTRACS. 1 May 2002: Note: Default cannot be changed in NTRACS. Changing default to :-4 results in :-: being displayed. Leave default as :- 5 'til NTRACS is fixed. NCTR-DataDictionary-22Jun2005 20 6/28/2005 ED Admission No Datapoint Description of Definitions NTRACS Standard NC Custom Options Optional/R Download Datapoint Datapoint Options equired Scenario History 131 OPRespTime Orthopedic surgeon Autogenerated. <-1> = Not Done/Doc Required if s 25 Sep 2000: response time No value unless (Default V2.5) Orthopedic Request emailed Team activated. <-5> = Not Available s called. to HG and KVM at (Default V3.1) NTRACS to add <-4>= Not Recorded Not Performed as an option. Note: Default value cannot be changed in NTRACS. 1 May 2002: Note: Default cannot be changed in NTRACS. Changing default to :-4 results in :-: being displayed. Leave default as :- 5 'til NTRACS is fixed. 132 EDORTimely Orthopedic surgeon "Timely" defined by NCTR-DataDictionary-22Jun2005 21 6/28/2005 ED Admission No Datapoint Description of Definitions NTRACS Standard NC Custom Options Optional/R Download Datapoint Datapoint Options equired Scenario History 134 ED_CRCall Time Chief Surgical Military time (00:00-<[sp][sp] :-3> = Pending Required if s 1 Mar 2002: New Resident called. 23:59) (V2.5) chief datapoint with <[sp][sp] :-1> = Not surgical V3.1. Done/Doc (Default V2.5) residents <[sp][sp] :-4> = Not respond to 1 May 2002: Recorded (Default V3.1) trauma Note: Default <[sp][sp] :-5> = Not activations cannot be Available and trauma changed in team NTRACS. activated. Changing default to :-4 results in :-: being displayed. Leave default as :- 5 'til NTRACS is fixed. 01Jan 2005: Defaults can be changed now NCTR-DataDictionary-22Jun2005 22 6/28/2005 ED Admission No Datapoint Description of Definitions NTRACS Standard NC Custom Options Optional/R Download Datapoint Datapoint Options equired Scenario History 135 ED_CRArrive Time of Surgical Chief Military time (00:00-<[sp][sp]:-3> = Pending Required if s 1 Mar 2002: New Resident's arrival at 23:59) (V2.5) chief datapoint with patient's bedside, in <[sp][sp]:-1> = Not surgical V3.1. ED, OR, or ICU. Done/Doc (Default V2.5) residents <[sp][sp]:-4> = Not respond to 1 May 2002: Recorded (Default V3.1) trauma Note: Default <[sp][sp]:-5> = Not activations cannot be Available and trauma changed in team NTRACS. activated. Changing default to :-4 results in :-: being displayed. Leave default as :- 5 'til NTRACS is fixed. 01Jan 2005: Defaults can be changed now 136 ED_CRResTim Surgical Senior Autocalculated <-1> = Not Done/Doc Required if s 1 Mar 2002: New Resident Response (Default V2.5) chief datapoint with Time (Minutes) <-4> = Not Recorded surgical V3.1. (Default V3.1) residents <-5> = Not Available respond to trauma activations and trauma team activated. NCTR-DataDictionary-22Jun2005 23 6/28/2005 ED Admission No Datapoint Description of Definitions NTRACS Standard NC Custom Options Optional/R Download Datapoint Datapoint Options equired Scenario History 137 ED_CRTimely Surgical Chief "Timely" defined by NCTR-DataDictionary-22Jun2005 24 6/28/2005 ED Admission No Datapoint Description of Definitions NTRACS Standard NC Custom Options Optional/R Download Datapoint Datapoint Options equired Scenario History 139 EDAnCall Time Anesthesia MD Military time (00:00-<[sp][sp] :-3> = Pending Required if s 1 Mar 2002: New called. 23:59) (V2.5) anesthesia datapoint with <[sp][sp] :-1> = Not called. V3.1. Done/Doc (Default V2.5) <[sp][sp] :-4> = Not Question: does Recorded (Default V3.1) this include <[sp][sp] :-5> = Not respiratory Available therapy or other airway- management person? 1 May 2002: Note: Default cannot be changed in NTRACS. Changing default to :-4 results in :-: being displayed. Leave default as :- 5 'til NTRACS is fixed. 01Jan 2005: Defaults can be changed now NCTR-DataDictionary-22Jun2005 25 6/28/2005 ED Admission No Datapoint Description of Definitions NTRACS Standard NC Custom Options Optional/R Download Datapoint Datapoint Options equired Scenario History 140 EDAnArriv Time Anesthesia MD Military time (00:00-<[sp][sp] :-3> = Pending Required if s 1 Mar 2002: New arrived at patient's 23:59) (V2.5) anesthesia datapoint with bedside, in ED, OR, or <[sp][sp] :-1> = Not called. V3.1. ICU. Done/Doc (Default V2.5) <[sp][sp] :-4> = Not Question: does Recorded (Default V3.1) this include <[sp][sp] :-5> = Not respiratory Available therapy or other airway- management person? 01Jan 2005: Defaults can be changed now 141 EDAnResTim Anesthesia MD Autocalculated <-1> = Not Done/Doc Required if s 1 Mar 2002: New Response Time (Default V2.5) anesthesia datapoint with (Minutes) <-4> = Not Recorded called. V3.1. (Default V3.1) <-5> = Not Available 1 May 2002: Note: Default Note: Default value cannot cannot be be changed in NTRACS. changed in NTRACS. 142 EDAnTimely Anesthesia MD arrival "Timely" defined by NCTR-DataDictionary-22Jun2005 26 6/28/2005 ED Assessment 1 No Datapoint Description of Definitions NTRACS Standard NC Custom Options Optional/ Download Datapoint History Datapoint Options Required Scenario 144 ED_Temp Initial temperature of <-1> = Not Done/Doc Required s,n 18 Oct 2000: Added patient in ED (Default V2.5) initial to datapoint <-3> = Pending (V2.5) description. <-4> = Not Recorded (Default V3.1) <-5> = Not Available <-6> = Not Performed 145 ED_Pulse Initial pulse rate in ED <-1> = Not Done/Doc Required s,n 18 Oct 2000: Added (Default V2.5) initial to datapoint <-3> = Pending (V2.5) description. <-4> = Not Recorded (Default V3.1) <-5> = Not Available <-6> = Not Performed 146 ED_Resp Initial respiratory rate Enter 0 if patient <-1> = Not Done/Doc Required s,n 18 Oct 2000: Added in ED intubated or (Default V2.5) initial to datapoint bagged. <-3> = Pending (V2.5) description. <-4> = Not Recorded (Default V3.1) <-5> = Not Available <-6> = Not Performed 147 EDRe_Manaq ED respiratory rate NCTR-DataDictionary-22Jun2005 1 6/28/2005 ED Assessment 1 No Datapoint Description of Definitions NTRACS Standard NC Custom Options Optional/ Download Datapoint History Datapoint Options Required Scenario 148 ED_BP Initial systolic blood <-1> = Not Done/Doc Required s,n 18 Oct 2000: Added pressure in ED (Default V2.5) initial to datapoint <-3> = Pending (V2.5) description. <-4> = Not Recorded (Default V3.1) <-5> = Not Available <-6> = Not Performed 149 ED_Eye Initial eye score on <1> = Does not open eyes Required s,n 18 Oct 2000: Added GCS in the ED <2> = Opens eyes to pain initial to datapoint <3> = Opens eyes to description. commands <4> = Spontaneous eye opening <-1> = Not Done/Doc (Default V2.5) <-3> = Pending (V2.5) <-4> = Not Recorded (Default V3.1) <-5> = Not Available <-6> = Not Performed NCTR-DataDictionary-22Jun2005 2 6/28/2005 ED Assessment 1 No Datapoint Description of Definitions NTRACS Standard NC Custom Options Optional/ Download Datapoint History Datapoint Options Required Scenario 150 ED_Vrb Initial verbal response <1> = No response Required s,n 18 Oct 2000: Added on GCS in the ED <2> = Incomprehensible initial to datapoint sounds description. <3> = Inappropriate words <4> = Disoriented and converses <5> = Oriented and converses <-1> = Not Done/Doc (Default V2.5) <-3> = Pending (V2.5) <-4> = Not Recorded (Default V3.1) <-5> = Not Available <-6> = Not Performed 151 ED_Mtr Initial motor response <1> = No response Required s,n 18 Oct 2000: Added on GCS in the ED <2> = Extends to pain initial to datapoint <3> = Flexes to pain description. <4> = Moves to pain <5> = Localizes pain <6> = Follows commands <-1> = Not Done/Doc (Default V2.5) <-3> = Pending (V2.5) <-4> = Not Recorded (Default V3.1) <-5> = Not Available <-6> = Not Performed NCTR-DataDictionary-22Jun2005 3 6/28/2005 ED Assessment 1 No Datapoint Description of Definitions NTRACS Standard NC Custom Options Optional/ Download Datapoint History Datapoint Options Required Scenario 152 ED_GCS Glasgow Coma Score Automatically <-1> = Not Done/Doc Required s,n 1 May 2002: Note: in the ED calculated by (Default V2.5) Default cannot be NTRACS. <-3> = Pending (V2.5) changed in <-4> = Not Recorded NTRACS. Leave (Default V3.1) default as -5 'til <-5> = Not Available NTRACS is fixed. Note: Default value cannot be changed in NTRACS. 153 ED_CalcaQ Assessment Qualifier 154 ED_TSArr Revised Trauma Automatically If values of the GCS, BP or Required s,n 1 May 2002: Note: Score in the ED calculated by Respiratory Rate are Default cannot be NTRACS. missing: changed in Based on the <-1> = Not Done/Doc NTRACS. Leave values of the (Default V2.5) default as -5 'til GCS, systolic <-4> = Not Recorded NTRACS is fixed. BP, and (Default V3.1) Respiratory Rate <-5> = Not Available Note: Default value cannot be changed in NTRACS. NCTR-DataDictionary-22Jun2005 4 6/28/2005 ED Assessment 1 No Datapoint Description of Definitions NTRACS Standard NC Custom Options Optional/ Download Datapoint History Datapoint Options Required Scenario 155 EDWCalcRTS Weighted RTS in ED Autocalculated If values of the GCS, BP or Required s 1 Mar 2002: New Respiratory Rate are datapoint with V3.1. missing: <-1> = Not Done/Doc 1 May 2002: Note: (Default V2.5) Default cannot be <-4> = Not Recorded changed in (Default V3.1) NTRACS. Leave <-5> = Not Available default as -5 'til NTRACS is fixed. Note: Default value cannot be changed in NTRACS. 156 ManED_GCS Manual Glasgow Use when any of <-1> = Not Done/Doc Optional s,n 18 Oct 2000: Coma Score in the ED 3 components of (Default V2.5) Completion of this ED GCS is <-4> = Not Recorded field is optional. missing. (Default V3.1) <-5> = Not Available 157 ED_ManaQ Assessment Qualifier NCTR-DataDictionary-22Jun2005 5 6/28/2005 ED Assessment 1 No Datapoint Description of Definitions NTRACS Standard NC Custom Options Optional/ Download Datapoint History Datapoint Options Required Scenario 158 ManED_TSArr Manual Revised Use when any of If values of the GCS, BP or Optional s,n 18 Oct 2000: Trauma Score in the the 3 Respiratory Rate are Completion of this ED components of missing: field is optional. the RTS is <-1> = Not Done/Doc missing. (Default V2.5) <-4> = Not Recorded (Default V3.1) <-5> = Not Available 159 EDWManRTS Manual Weighted RTS Use when any of If values of the GCS, BP or Optional s 1 Mar 2002: New in ED the 3 Respiratory Rate are datapoint with V3.1. components of missing: the RTS is <-1> = Not Done/Doc missing. (Default V2.5) <-4> = Not Recorded (Default V3.1) <-5> = Not Available NCTR-DataDictionary-22Jun2005 6 6/28/2005 ED Assessment 1 No Datapoint Description of Definitions NTRACS Standard NC Custom Options Optional/ Download Datapoint History Datapoint Options Required Scenario 160 Airway Airway management 28 Jul 2004: Added Scene-ETT, Scene- Cric, Refer-ETT, Refer-Cric . NCTR-DataDictionary-22Jun2005 7 6/28/2005 ED Assessment 1 No Datapoint Description of Definitions NTRACS Standard NC Custom Options Optional/ Download Datapoint History Datapoint Options Required Scenario 161 CPR CPR management in 28 Jul 2004: added NCTR-DataDictionary-22Jun2005 8 6/28/2005 ED Assessment 1 No Datapoint Description of Definitions NTRACS Standard NC Custom Options Optional/ Download Datapoint History Datapoint Options Required Scenario 162 Blood_No Units of blood given in Includes blood # of units administered to <999> = Blood is Optional s,n 18 Oct 2000: Added first 24 hours given at referring patient in first 24 hrs. administered in first 24 999 as a custom hospital, ED or Enter 0 if it is known that no hours, but amount is value to indicate hospital in 1st 24 blood was given. unknown. when blood is hours post <-1> = Not Done/Doc administered in first injury. Includes (Default V2.5) 24 hours, but whole blood, <-3> = Pending (V2.5) amount is unknown. packed red <-4> = Not Recorded Added note: blood cells, auto- (Default V3.1) Includes blood given transfused or <-5> = Not Available at referring hospital, cell saver blood ED or hospital in 1st that does not 24 hours post injury. include platelets, fresh frozen 20 Feb 2002: This plasma, or field has variable cryoprecipitate. reliability even within institutions. Very difficult to tell what type of blood is given. Not valid for research on a statewide basis. NCTR-DataDictionary-22Jun2005 9 6/28/2005 ED Assessment 1 No Datapoint Description of Definitions NTRACS Standard NC Custom Options Optional/ Download Datapoint History Datapoint Options Required Scenario 163 ETOH Initial Blood Alcohol mg/l (range=0- <-1> = Not Done/Doc <700> = Suspected Required s,n 18 Oct 2000: 164 Hct Hematocrit value: Range=0-80. <-1> = Not Done/Doc Required s,n 18 Oct 2000: <-6> initial value from your (Default V.25) (Not Performed) hospital. <-3> = Pending (V2.5) added as a custom <-4> = Not Recorded field value. (Default V3.1) Changed definition <-5> = Not Available from Initial value <-6> = Not Performed from first hospital from which patient received care for this injury to initial value from your hospital. If Hgb x 3 is used in lieu of Hct, notify the CDCA so a record can be kept. This substitution is used by CMC, Cleveland. NCTR-DataDictionary-22Jun2005 10 6/28/2005 ED Assessment 1 No Datapoint Description of Definitions NTRACS Standard NC Custom Options Optional/ Download Datapoint History Datapoint Options Required Scenario 165 BaseDef Initial Base Deficit at Range = +/-80. Base Deficit Required s,n 18 Oct 2000: Added your hospital <-81> = Not Done/Doc <-86> = Not (Default V2.5), Performed Not Recorded (Default (Procedure not V3.1) done) as a custom <-82> = Not Performed field value. <-83> = Pending (V2.5), Not Available (V3.1) 16 May 2002: Changed Not Performed to <-82> to compensate for NTRACS limitations. NCTR-DataDictionary-22Jun2005 11 6/28/2005 ED Assessment 1 No Datapoint Description of Definitions NTRACS Standard NC Custom Options Optional/ Download Datapoint History Datapoint Options Required Scenario 166 Drug_Scrn Initial Drug screen NCTR-DataDictionary-22Jun2005 12 6/28/2005 ED Assessment 1 No Datapoint Description of Definitions NTRACS Standard NC Custom Options Optional/ Download Datapoint History Datapoint Options Required Scenario 166 Drug_Scrn Drug Screen 1 Mar 2002: No (Continued) longer will use Poly Drugs, Poly Drugs - L, since multiple drugs can be entered with V3.1. NCTR-DataDictionary-22Jun2005 13 6/28/2005 ED Assessment 2 No Datapoint Description of Definitions NTRACS Standard Options NC Custom Options Optional/Re Download Datapoint History Datapoint quired Scenario 166.1 HeadCT Initial Head CT NCTR-DataDictionary-22Jun2005 1 6/28/2005 ED Assessment 2 No Datapoint Description of Definitions NTRACS Standard Options NC Custom Options Optional/Re Download Datapoint History Datapoint quired Scenario 166.3 AssHCTTime Head CT Time Time that first <[sp][sp]: -3> = Pending Required if s,n 1 Mar 2002: New head CT scan was (V2.5) HeadCT datapoint with V3.1. completed. <[sp][sp]: -1> = Not performed. Military time (00:00-Done/Doc (Default V2.5) 1 May 2002: Note: 23:59) <[sp][sp]: -4> = Not Default cannot be Recorded (Default V3.1) changed in <[sp][sp]: -5> = Not NTRACS. Available Changing default to :-4 results in :-: being displayed. Leave default as :-5 'til NTRACS is fixed. 01Jan 2005: Defaults can be changed now 166.4 AbdCT Initial Abdominal NCTR-DataDictionary-22Jun2005 2 6/28/2005 ED Assessment 2 No Datapoint Description of Definitions NTRACS Standard Options NC Custom Options Optional/Re Download Datapoint History Datapoint quired Scenario 166.5 AssACTDate Abdominal CT Date that first mm/dd/yyyy Required if s,n 1 Mar 2002: New Date abdominal CT Default = blank. Abdominal datapoint with V3.1. scan was CT completed performed. 166.6 AssACTTime Abdominal CT Time that first <[sp][sp]: -3> = Pending Required if s,n 1 Mar 2002: New Time abdominal CT (V2.5) Abdominal datapoint with V3.1. scan was <[sp][sp] :-1> = Not CT completed. Done/Doc (Default V2.5) performed. 1 May 2002: Note: Military time (00:00-<[sp][sp] :-4> = Not Default cannot be 23:59) Recorded (Default V3.1) changed in <[sp][sp]: -5> = Not NTRACS. Available Changing default to :-4 results in :-: being displayed. Leave default as :-5 'til NTRACS is fixed. 01Jan 2005: Defaults can be changed now NCTR-DataDictionary-22Jun2005 3 6/28/2005 ED Assessment 2 No Datapoint Description of Definitions NTRACS Standard Options NC Custom Options Optional/Re Download Datapoint History Datapoint quired Scenario 167 AssAbdUSou Initial abdominal 168 AssAUSDate Abdominal US Date that first mm/dd/yyyy Required if s 1 Mar 2002: New Date abdominal US Default = blank. Abdominal datapoint with V3.1. scan was US completed performed. NCTR-DataDictionary-22Jun2005 4 6/28/2005 ED Assessment 2 No Datapoint Description of Definitions NTRACS Standard Options NC Custom Options Optional/Re Download Datapoint History Datapoint quired Scenario 169 AssAUSTime Abdominal US Time that first <[sp][sp]: -3> = Pending Required if s 1 Mar 2002: New Time abdominal US (V2.5) Abdominal datapoint with V3.1. scan was <[sp][sp]: -1> = Not US Replaces custom completed. Done/Doc (Default V2.5) performed. datapoint Military time (00:00-<[sp][sp]: -4> = Not AbCTTime. 23:59) Recorded (Default V3.1) <[sp][sp]: -5> = Not 1 May 2002: Note: Available Default cannot be changed in NTRACS. Changing default to :-4 results in :-: being displayed. Leave default as :-5 'til NTRACS is fixed. 01Jan 2005: Defaults can be changed now 170 AssChestCT Chest CT results NCTR-DataDictionary-22Jun2005 5 6/28/2005 ED Assessment 2 No Datapoint Description of Definitions NTRACS Standard Options NC Custom Options Optional/Re Download Datapoint History Datapoint quired Scenario 171 AssCCTDate Chest CT Date Date that first mm/dd/yyyy Required if s 1 Mar 2002: New chest CT scan Default = blank. chest CT datapoint with V3.1. was completed performed. 172 AssCCTTime Time that first Military time (00:00-<[sp][sp]: -3> = Pending Required if s 1 Mar 2002: New chest CT scan 23:59) (V2.5) chest CT datapoint with V3.1. was completed. <[sp][sp]: -1> = Not performed. Replaces custom Done/Doc (Default V2.5) datapoint <[sp][sp]: -4> = Not HdCTTime. Recorded (Default V3.1) <[sp][sp]: -5> = Not 1 May 2002: Note: Available Default cannot be changed in NTRACS. Changing default to :-4 results in :-: being displayed. Leave default as :-5 'til NTRACS is fixed. 01Jan 2005: Defaults can be changed now NCTR-DataDictionary-22Jun2005 6 6/28/2005 ED Assessment 2 No Datapoint Description of Definitions NTRACS Standard Options NC Custom Options Optional/Re Download Datapoint History Datapoint quired Scenario 173 PerLav Initial diagnostic 28 Jul 2004: Added 174 AssPlvDate Date first mm/dd/yyyy Required if s 1 Mar 2002: New peritoneal Default = blank. PerLav datapoint with V3.1. lavage was performed. performed. NCTR-DataDictionary-22Jun2005 7 6/28/2005 ED Assessment 2 No Datapoint Description of Definitions NTRACS Standard Options NC Custom Options Optional/Re Download Datapoint History Datapoint quired Scenario 175 AssPlvTime Time first Military time (00:00-<[sp][sp]: -4> = Not Required if s 1 Mar 2002: New peritoneal 23:59) Recorded (Default V3.1) PerLav datapoint with V3.1. lavage was <[sp][sp]: -5> = Not performed. performed. Available 1 May 2002: Note: Default cannot be changed in NTRACS. Changing default to :-4 results in :-: being displayed. Leave default as :-5 'til NTRACS is fixed. 01Jan 2005: Defaults can be changed now 176 AssAortoGr Aortogram NCTR-DataDictionary-22Jun2005 8 6/28/2005 ED Assessment 2 No Datapoint Description of Definitions NTRACS Standard Options NC Custom Options Optional/Re Download Datapoint History Datapoint quired Scenario 178 AssAorTime Aortogram Time Military time (00:00-<[sp][sp]: -4> = Not Required if s 1 Mar 2002: New 23:59) Recorded (Default V3.1) Aortogram datapoint with V3.1. <[sp][sp]: -5> = Not performed. Available 1 May 2002: Note: Default cannot be changed in NTRACS. Changing default to :-4 results in :-: being displayed. Leave default as :-5 'til NTRACS is fixed. NCTR-DataDictionary-22Jun2005 9 6/28/2005 ED Assessment 2 No Datapoint Description of Definitions NTRACS Standard Options NC Custom Options Optional/Re Download Datapoint History Datapoint quired Scenario 179 AGram Initial 180 Ass_AntDate Arteriogram/Angi mm/dd/yyyy Required if s 1 Mar 2002: New ogram Date Default = blank. Arteriogram/ datapoint with V3.1. Angiogram performed. NCTR-DataDictionary-22Jun2005 10 6/28/2005 ED Assessment 2 No Datapoint Description of Definitions NTRACS Standard Options NC Custom Options Optional/Re Download Datapoint History Datapoint quired Scenario 181 Ass_AntTime Arteriogram/Angi Military time (00:00-<[sp][sp]: -4> = Not Required if s 1 Mar 2002: New ogram Time 23:59) Recorded (Default V3.1) Arteriogram/ datapoint with V3.1. <[sp][sp]: -5> = Not Angiogram Available performed. 1 May 2002: Note: Default cannot be changed in NTRACS. Changing default to :-4 results in :-: being displayed. Leave default as :-5 'til NTRACS is fixed. 01Jan 2005: Defaults can be changed now NCTR-DataDictionary-22Jun2005 11 6/28/2005 ED Assessment 2 No Datapoint Description of Definitions NTRACS Standard Options NC Custom Options Optional/Re Download Datapoint History Datapoint quired Scenario 182 ED_Disp ED disposition of NCTR-DataDictionary-22Jun2005 12 6/28/2005 ED Assessment 2 No Datapoint Description of Definitions NTRACS Standard Options NC Custom Options Optional/Re Download Datapoint History Datapoint quired Scenario 182 ED_Disp ED disposition of 28 Jul 2004: Added patient NCTR-DataDictionary-22Jun2005 13 6/28/2005 ED Assessment 2 No Datapoint Description of Definitions NTRACS Standard Options NC Custom Options Optional/Re Download Datapoint History Datapoint quired Scenario 183 AdmService Admitting 184 AssORDisp OR Disposition NCTR-DataDictionary-22Jun2005 14 6/28/2005 ED Assessment 2 No Datapoint Description of Definitions NTRACS Standard Options NC Custom Options Optional/Re Download Datapoint History Datapoint quired Scenario 185 AssAdmMD Admitting MD Name of physician Optional d 1 Mar 2002: New 01Jan 2005: Defaults appear to be changed, but they do not work properly NCTR-DataDictionary-22Jun2005 15 6/28/2005 ED Assessment 2 No Datapoint Description of Definitions NTRACS Standard Options NC Custom Options Optional/Re Download Datapoint History Datapoint quired Scenario 186 AssAttMD Attending MD Name of physician Optional d 1 Mar 2002: New 01Jan2005: Defaults appear to be changed, but they do not work properly NCTR-DataDictionary-22Jun2005 16 6/28/2005 ED Assessment 2 No Datapoint Description of Definitions NTRACS Standard Options NC Custom Options Optional/Re Download Datapoint History Datapoint quired Scenario 187 ConsCode Consult Code Consults within NCTR-DataDictionary-22Jun2005 17 6/28/2005 ED Assessment 2 No Datapoint Description of Definitions NTRACS Standard Options NC Custom Options Optional/Re Download Datapoint History Datapoint quired Scenario 187 ConsCode Consult Code 28 Jul 2004: Added (continued) 189 ConsDate Consult Date Date initial ED Default = blank Required if s 1 Mar 2002: New consult was consult datapoint with V3.1. documented. entered. NCTR-DataDictionary-22Jun2005 18 6/28/2005 ED Assessment 2 No Datapoint Description of Definitions NTRACS Standard Options NC Custom Options Optional/Re Download Datapoint History Datapoint quired Scenario 190 ConsTime Consult Time Time of initial ED <[sp][sp] :-4> = Not Optional s 1 Mar 2002: New consult. Recorded (Default V3.1) datapoint with V3.1. Military time (00:00-<[sp][sp] :-5> = Not 23:59) Available 1 May 2002: Note: Default cannot be Note: Default value cannot changed in be changed in NTRACS. NTRACS. Changing default to :-4 results in :-: being displayed. Leave default as :-5 'til NTRACS is fixed. 01 Jan 2005: It appears as if the defualt value can be changed, but it does not work properly NCTR-DataDictionary-22Jun2005 19 6/28/2005 Hospital Diagnoses No Datapoint Description of Definitions NTRACS Standard NC Custom Options Optional/ Download Datapoint History Datapoint Options Required Scenario 191 DCode ICD-9 diagnosis codes May include Default = Blank. Required s,n comorbidities. 192 AISCode AIS 90 code See coding guidelines Default = Blank. Required s,n for each dcode. 193 USRAIS_Abd AIS Abdomen Entered automatically <-1> = Not Done/Doc Required s,n 1 May 2002: Note: based on AIS 90 (Default V2.5) for each Default cannot be <-4> = Not Recorded dcode. changed in (Default V3.1) NTRACS. Leave <-5> = Not Available default as -5 'til If value = 9, then ISS NTRACS is fixed. score (usrais_iss) will not be calculated. Note: Default value cannot be changed in NTRACS. 194 USRAIS_HN AIS Head/Neck region Entered automatically <-1> = Not Done/Doc Required s,n 1 May 2002: Note: based on AIS 90 (Default V2.5) for each Default cannot be <-4> = Not Recorded dcode. changed in (Default V3.1) NTRACS. Leave <-5> = Not Available default as -5 'til If value = 9, then ISS NTRACS is fixed. score (usrais_iss) will not be calculated. Note: Default value cannot be changed in NTRACS. NCTR-DataDictionary-22Jun2005 1 6/28/2005 Hospital Diagnoses No Datapoint Description of Definitions NTRACS Standard NC Custom Options Optional/ Download Datapoint History Datapoint Options Required Scenario 195 USRAIS_Chs AIS Chest region Entered automatically <-1> = Not Done/Doc Required s,n 1 May 2002: Note: based on AIS 90 (Default V2.5) for each Default cannot be <-4> = Not Recorded dcode. changed in (Default V3.1) NTRACS. Leave <-5> = Not Available default as -5 'til If value = 9, then ISS NTRACS is fixed. score (usrais_iss) will not be calculated. Note: Default value cannot be changed in NTRACS. 196 USRAIS_Ext AIS Extremities region Entered automatically <-1> = Not Done/Doc Required s,n 1 May 2002: Note: based on AIS 90 (Default V2.5) for each Default cannot be <-4> = Not Recorded dcode. changed in (Default V3.1) NTRACS. Leave <-5> = Not Available default as -5 'til If value = 9, then ISS NTRACS is fixed. score (usrais_iss) will not be calculated. Note: Default value cannot be changed in NTRACS. NCTR-DataDictionary-22Jun2005 2 6/28/2005 Hospital Diagnoses No Datapoint Description of Definitions NTRACS Standard NC Custom Options Optional/ Download Datapoint History Datapoint Options Required Scenario 197 USRAIS_Face AIS Face region Entered automatically <-1> = Not Done/Doc Required s,n 1 May 2002: Note: based on AIS 90 (Default V2.5) for each Default cannot be <-4> = Not Recorded dcode. changed in (Default V3.1) NTRACS. Leave <-5> = Not Available default as -5 'til If value = 9, then ISS NTRACS is fixed. score (usrais_iss) will not be calculated. Note: Default value cannot be changed in NTRACS. 198 USRAIS_ST AIS Skin/Soft Tissue Entered automatically <-1> = Not Done/Doc Required s,n 1 May 2002: Note: region based on AIS 90 (Default V2.5) for each Default cannot be <-4> = Not Recorded dcode. changed in (Default V3.1) NTRACS. Leave <-5> = Not Available default as -5 'til If value = 9, then ISS NTRACS is fixed. score (usrais_iss) will not be calculated. Note: Default value cannot be changed in NTRACS. 199 USRAIS_ISS Injury Severity Score Sum of squares of <-1> = Not Done/Doc Required s,n 1 May 2002: Note: highest AIS code in (Default V2.5) for each Default cannot be Autocalculated each of the three most <-4> = Not Recorded dcode. changed in severely injured AIS (Default V3.1) NTRACS. Leave body regions <-5> = Not Available default as -5 'til NTRACS is fixed. Note: Default value cannot be changed in NTRACS. NCTR-DataDictionary-22Jun2005 3 6/28/2005 Hospital Diagnoses No Datapoint Description of Definitions NTRACS Standard NC Custom Options Optional/ Download Datapoint History Datapoint Options Required Scenario 199.1 NISS New Injury Severity Sum of squares of the <-5> = Not Available Score 3 highest AIS codes, (Default V3.4) regardless of body Autocalculated region Note: Default value cannot be changed in NTRACS 200 MANAIS_Abd Manually entered AIS Do not use this field <-1> = Not Done/Doc 18 Oct s,n for Abdomen region unless there is a (Default V2.5) 2000: revision to the AIS <-4> = Not Recorded Optional (Default V3.1) field. <-5> = Not Available 201 MANAIS_Chs Manually-entered AIS Do not use this field <-1> = Not Done/Doc 18 Oct s,n for Chest region unless there is a (Default V2.5) 2000: revision to the AIS <-4> = Not Recorded Optional (Default V3.1) field. <-5> = Not Available 202 MANAIS_Ext Manually entered AIS Do not use this field <-1> = Not Done/Doc 18 Oct s,n for Extremities region unless there is a (Default V2.5) 2000: revision to the AIS <-4> = Not Recorded Optional (Default V3.1) field. <-5> = Not Available 203 MANAIS_Fac Manually entered AIS Do not use this field <-1> = Not Done/Doc 18 Oct s,n for Face region unless there is a (Default V2.5) 2000: revision to the AIS <-4> = Not Recorded Optional (Default V3.1) field. <-5> = Not Available 204 ManAIS_HN Manually entered AIS Do not use this field <-1> = Not Done/Doc 18 Oct s,n for Head/Neck region unless there is a (Default V2.5) 2000: revision to the AIS <-4> = Not Recorded Optional (Default V3.1) field. <-5> = Not Available NCTR-DataDictionary-22Jun2005 4 6/28/2005 Hospital Diagnoses No Datapoint Description of Definitions NTRACS Standard NC Custom Options Optional/ Download Datapoint History Datapoint Options Required Scenario 205 ManAIS_ST Manually entered AIS Do not use this field <-1> = Not Done/Doc 18 Oct s,n for Skin/Soft Tissue unless there is a (Default V2.5) 2000: region revision to the AIS <-4> = Not Recorded Optional (Default V3.1) field. <-5> = Not Available 206 ManAIS_ISS Manually entered ISS Do not use this field Valid range: 1 - 75 18 Oct s,n score unless there is a <-1> = Not Done/Doc 2000: revision to the AIS (Default V2.5) Optional <-4> = Not Recorded field. (Default V3.1) <-5> = Not Available 207 ProbOfSurv Probability of survival Calculated using the <-1> = Not Done/Doc Required s,n 1 May 2002: Note: TRISS methodology (Default V2.5) for each Default cannot be <-4> = Not Recorded dcode. changed in Automatically entered (Default V3.1) NTRACS. Leave after NTRACS has <-5> = Not Available default as -5 'til RTS, ISS, age, and NTRACS is fixed. type of injury. Note: Default value cannot be changed in NTRACS. 208 Operative Operative Therapy Did patient undergo NCTR-DataDictionary-22Jun2005 5 6/28/2005 Comorbidities No Datapoint Description of Definitions NTRACS Standard NC Custom Options Optional/ Download Datapoint History Datapoint Options Required Scenario 209 Action Action taken based on Free text field. Optional d 1 Mar 2002: New comorbidity. Default = blank. datapoint with V3.1. 210 ComorCode Comorbidity Code Pre-existing See NTRACS data Optional s 1 Mar 2002: New comorbidity dictionary for pick-list datapoint with V3.1. options. Default = blank. 211 ComorComme Comorbidity Comment Free text field. Optional d 1 Mar 2002: New Default = blank. datapoint with V3.1. NCTR-DataDictionary-22Jun2005 1 6/28/2005 Procedures No Datapoint Description of Definitions NTRACS Standard NC Custom Optional/ Download Datapoint History Datapoint Options Options Required Scenario 212 OpCode ICD-9 procedure code Default = blank. Required s,n 18 Oct 2000: Required for all OR procedures. 213 OpDate Date of mm/dd/yyyy Default = blank. Required s,n 18 Oct 2000: Required operation/procedure for each for all OR procedures. opcode. 214 OpTime Time of Military time (00:00- <[sp][sp] :-3> = Pending Required s,n 18 Oct 2000: Added operation/procedure = 23:59) (V2.5) for each Time of start of time of start of <[sp][sp] :-1> = Not opcode. anesthesia to anesthesia. Done/Doc (Default V2.5) description. Discussed <[sp][sp] :-4> = Not anesthesia start time Recorded (Default V3.1) versus time of 1st <[sp][sp] :-5> = Not incision. Decided to Available use anesthesia start time. Required for all OR procedures. 01Jan 2005: Defaults can be changed now 215 AtPhCode Attending physician User defined Optional d 01 Jan 2005: It code: surgeon who appears defaults can performed operation. Note: Default value be changed, but they cannot be changed in do not work properly NTRACS. NCTR-DataDictionary-22Jun2005 1 6/28/2005 Procedures No Datapoint Description of Definitions NTRACS Standard NC Custom Optional/ Download Datapoint History Datapoint Options Options Required Scenario 216 OpTimePstd Operation time posted Time at which the OR <[sp][sp] :-3> = Pending Optional s,n 18 Oct 2000: This was notified by the (V2.5) information is not trauma surgeon that <[sp][sp] :-1> = Not obtainable by the an OR would be Done/Doc (Default V2.5) Registrars. Changed needed. <[sp][sp] :-4> = Not to optional field. Recorded (Default V3.1) Military time (00:00- <[sp][sp] :-5> = Not 01Jan 2005: Defaults 23:59) Available can be changed now 217 OpLocation Operative location 01Jan 2005: Defaults can be changed now NCTR-DataDictionary-22Jun2005 2 6/28/2005 Complications No Datapoint Description of Definitions NTRACS Standard Options NC Custom Optional/ Download Datapoint History Datapoint Options Required Scenario 219 TCode Complication Default = blank. 18 Oct 2000: s,n code from Required TRACS field. = Chemically leave a patient sedated chemically sedated. = Chemically is given a value sedated other than -1. = Patient chemically entered sedated = Chemically sedated procedures and = Chemically sedated if Maned_gcs is