North Carolina Trauma Registry (NCTR) Data Dictionary NCTR Data Dictionary

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

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