HOSPITAL DATA DICTIONARY Texas Department of Health Trauma Registry July 24, 2001 TABLE OF CONTENTS Definitions ii 2002 Data File Formats iii Pre-existing Conditions………………………... 17 Patient Demographics Injury Severity Score…………………….……. 18 Trauma Registry Number……………………... 1 (Body Region) Injury Severity……….……….. 18 Patient’s Name……………………….………... 1 (Body Region) Type of Injury…….…………... 18 Patient’s Social Security Number………….….. 1 Facility Number………………………..……… 2 Patient Hospital Cost Medical Record Number………………………. 2 Payor Category……………..………………….. 19 Race …………………………………………… 2 Billed Hospital Charges………….……………. 20 Gender ……..……….………….…………….. 2 Total Reimbursement……………….…………. 20 Date of Birth…………………………………... 3 Prehospital Data Date of Injury……….…………..……………... 3 Respiratory Rate at Scene……………………... 21 County of Injury………………..……………… 4 Systolic Blood Pressure at Scene……………… 21 Cause of Injury…………………..…………….. 4 Motor Response at Scene……………………… 22 Time of Injury…………………..……………... 4 Verbal Response at Scene……………………... 22 County of Residence…………..………………. 5 Eye Opening Response at Scene.……..……….. 23 Place of Injury…………………..……………... 5 Glasgow Coma Score at Scene…………..……. 23 Hospital Admission Transport Date of Arrival………………………………… 7 TDH Firm Number………………….………… 24 Time of Arrival………………………………... 7 Time of Dispatch….………………………….... 24 Alcohol Level Tested………………………….. 8 Time of Scene Arrival……….………………… 25 Alcohol Level………………...……………….. 8 Time of Leaving Scene…………….………….. 25 Systolic Blood Pressure…………...…………... 8 Vehicle Extrication……………….……….…... 26 Diastolic Blood Pressure………………………. 8 Protective Device……………………………… 26 Respiration Rate……………………………….. 9 Transfer Status Pulse…………………………………………… 9 Is this a Transfer……………………………….. 27 Glasgow Coma Scale at Admission First Hospital Number………………………..... 27 Motor Response……………………………….. 10 Date of Arrival to First Hospital………………. 28 Verbal Response………………………...…….. 10 Time of Arrival to First Hospital………...……. 28 Eye Opening Response……………….……….. 11 Date of Departure from First Hospital………… 29 Glasgow Coma Score at Admission……...…… 11 Time of Departure from First Hospital………... 29 Revised Trauma Score at Admission Additional Fields Glasgow Coma Score for Revised Trauma City of Residence 30 Score…………………………………………... 12 Trauma Team Activation 30 Respiratory Rate for Trauma Score………….... 12 Time of Trauma Team Activation 30 Systolic Blood Pressure for Trauma Score….… 12 Software Identification 31 Revised Trauma Score……...…………………. 13 Research Fields 32 Hospital Discharge Desired Fields 33 Patient Discharged To………………...……….. 14 Appendices Condition on Discharge……………..………… 14 Appendix A – Hospital Code List……………... 47 Date of Discharge or Death…………..…….….. 15 Appendix B – EMS Provider Code List………. 54 Time of Discharge or Death…………..……….. 15 Appendix C – County Code List………………. 62 Patient Discharged to Facility Number……..…. 16 Appendix D – City/County Code List………… 63 Length of Stay………………..………...……… 16 Appendix E – Glasgow Coma Score Chart…… 75 ICU Length of Stay……………..…………...… 16 Appendix F – Diagnosis 1-5 (ICD9CM Coding Diagnosis, Procedures, and Scheme)………………………………………... 76 Severity Scores Appendix G – Glossary………………………... 78 Diagnoses…………………..………………….. 17 Appendix H – Data File Creation and Transfer Abbreviated Injury Scale…………..……….…. 17 Specifications………………………………….. 79 Procedures……………….…………....……….. 17 Appendix I – Software ID Codes ….………….. 80 i Definitions Vendor Software Application The Hospital Data Dictionary describes the format of files electronically transmitted to the Texas Department of Health (TDH) EMS/Trauma Registry. Trauma registry software does not have to list fields or values in the same order as presented in the data dictionary, for the purpose of data entry, as long as the data file sent to the state is in the correct format. Injury Website The Injury website can be found by using an Internet browser to access http://www.tdh.state.tx.us/injury/. The Trauma Registry section of this website includes hospital/EMS/county/software codes, participations reports, hospital and EMS Trauma Registry Guidelines. Data Field Number The position of each field within the record. The order in which the field should appear within the record relative to other fields in the record contained in the data file to be transmitted to the EMS/Trauma Registry. Data Field Name The name of the field in the database. Required/Optional Defines whether or not entering/assigning a value to the field is required. “Required” means that a valid value MUST be entered/assigned. “Required – Conditional” means that a valid value MUST be entered/assigned if the defined conditions are true. “Optional” means data entry is at the discretion of each individual hospital. “Do Not Report” means that data should not be entered because the EMS/Trauma Registry no longer uses the data. If your software automatically inserts data into these fields, it will be ignored. The “Do Not Report” fields were left in the data dictionary so that no one would have to drastically alter their current data submission software. Any data fields not containing data must still be delimited with a tab (see 2002 Data File Formats). Max. Length of Field, Type of Field, and Value Range These describe the formatting requirements of the field. DEFN The definition of the field. Values These are the acceptable values that can be electronically transmitted to the EMS/Trauma Registry. The typical format is: [value or value range] = [definition of value or value range] Definitions of values and terms are supplied where appropriate but should NOT be transmitted to the EMS/Trauma Registry. File Format for Electronic Transmission Before sending your data to the Texas EMS/Trauma Registry, please make sure that the order of the fields for each record in your file is the same as the order described by the Data Field Number. The Texas EMS/Trauma Registry computer accepts only ASCII data delimited with TABS. There should be a TAB after each field, the only exception being the last field of a record. More information concerning file format can be found in the next section called 2002 Data File Formats. ii 2002 Data File Formats Due to recent legislation, and the Texas Department of Health TRAC-IT initiative, the Texas EMS/Trauma Registry (herein referred to as The Registry) will make some exciting changes. New hospital and EMS data sets will be effective starting January 2002. It will be more important than ever to send your data files containing the data sets in the correct format. All data files that are sent to The Registry must be in ASCII tab-delimited format. A tab must follow every field except the last field of each record. Even if there is no data recorded for a particular field, or the field is optional, a tab must still be placed in that field’s position. A new line feed and carriage return must follow every record, after the last field of each record, except for the last record of the file. The first line of the data file must contain the first record to be transmitted and the last line of the data file must contain the last record to be transmitted. The order of the records in the data file has no effect on how they are processed. Warning: Opening and saving a data file with text editors (MS Word, WordPad, WordPerfect) can corrupt the data file with special codes inserted by the text editor. There are three different record lengths that may be sent for each data set. These three lengths correspond to the major sections of the new data sets. The hospital and EMS data sets are both divided into three major sections: Main Fields, Research Fields, and Desired Fields. Main Fields is not the formal name of the first section as presented in each data dictionary but that is how the first section of fields will be referred to in this explanation. The Main Fields section contains the minimum standard data set that everyone is required to send to The Registry. A file sent in the Main Format must contain all of the fields in the Main Fields section of the appropriate data set. The Research Fields section contains fields that are all optional. A file sent in the Research Format must contain all of the fields in the Main Fields section of the appropriate data set as well as ALL nine fields of the Research Fields section. The Desired Fields section contains fields that are all optional and include audit/QI filters typically used by hospitals and EMS. A file sent in the Desired Format must contain all of the fields in the Main Fields section of the appropriate data set, all nine fields of the Research Fields section, AND all of the fields of the Desired Fields section. In simple English, if you only wish to meet State requirements, you must send a data file with all of the fields listed in the Main Fields section of each data set. If you wish to send data which includes any of the Research Fields, you must send all of the Main Fields and all of the Research Fields, even if you did not use all of them. If you send data which includes any of the Desired Fields, your data file must include all of the fields from all three sections. Following is a chart which diagrams the number of fields per record you must have in each line of the data file based on the format you are using. Main Format Research Format Desired Format Main Fields Main + Research Fields Main + Research + Desired Fields Hospital 121 130 182 EMS 106 115 136 iii HOSPITAL DATA DICTIONARY PATIENT DEMOGRAPHICS TRAUMA REGISTRY NUMBER Data Field Number: 1 Data Field Name: TRNO Required/Optional: Required Max. Length of Field: 7 Type of Field: Numerical Value Range: 1 - 9999999 DEFN Sequential unique number assigned by the registry software program or registrar. PATIENT’S LAST NAME Data Field Number: 2 Data Field Name: LNAME Required/Optional: Optional Max. Length of Field: 20 Type of Field: Character Value Range: None DEFN The patient’s legal last name. PATIENT’S FIRST NAME Data Field Number: 3 Data Field Name: FNAME Required/Optional: Optional Max. Length of Field: 20 Type of Field: Character Value Range: None DEFN The patient’s legal first name. PATIENT’S MIDDLE INITIAL Data Field Number: 4 Data Field Name: MI Required/Optional: Optional Max.