HOSPITAL DATA DICTIONARY FINAL DRAFT Texas Department of Health Trauma Registry December 2, 1999 Acknowledgements Special recognition is due to the Trauma Registry Workgroup members who devoted time and effort toward the development of the hospital data dictionary. Their commitment and hard work are greatly appreciated. Workgroup members include Larry Baggett (Baptist St. Anthony’s Hospital), Phyllis Blanco (Medical Center), Mike Clark (Hermann Hospital), Maggie Crawford (University Medical Center in Lubbock), Michelle Drum (Covenant Medical Center), Judy England (East Texas Medical Center), Gary Kesling (University of Texas Medical Branch), Jim Lyons (Falls County EMS), Cathy McMahon (Covenant Medical Center), Marjorie Mellott (Val Verde Regional Medical Center), Jim Owen (Brooke Army Medical Center), and Charlene Seale (Northwest Texas Health Care System). Special thanks also goes to the Texas Department of Health /Bureau of Emergency Medical Services staff for their involvement with the Workgroup: Tracy Cotner-Pouncy, Brian Haschke, Kathy Perkins, and Carol Wright. Texas Trauma Registry staff include: Jennifer Hunteman (Program Administrator), Dale Cherry (Research Specialist), Andy Blum (Trauma Registry Specialist) and David Zane (Director, Injury Epidemiology and Surveillance). Special acknowledgement goes to Texas hospitals, other state trauma registries, and the American College of Surgeons for providing data dictionaries: Brackenridge Hospital, Children's Medical Center, Parkland Hospital, National Trauma Data Bank (American College of Surgeons), Maryland Trauma Registry, Oregon Trauma Registry, Pennsylvania Trauma Systems Foundation, and Washington Trauma Registry. Data Dictionary Development Process The hospital data dictionary was developed by the Trauma Registry Workgroup. This fifteen member group was formed in May 1999 to address various trauma registry issues including the development of the data dictionary. The data dictionary development process involved reviewing each data field to determine if each field should be Required or Optional. The Workgroup then reviewed several existing data dictionaries. Based on definitions from these dictionaries and discussions of each data field, the Workgroup developed draft definitions. While defining the fields, the Workgroup also answered field-specific questions that hospital personnel had submitted to the state Trauma Registry. In August 1999, the draft data dictionary was distributed to hospitals, the Texas Trauma Coordinators Forum, Emergency Health Care Advisory Council (EHCAC), Regional Advisory Councils (RACs), and software vendors for review and comment. On September 1999, the Workgroup met to review comments and make appropriate changes. A final draft will be distributed in November. A copy of the data dictionary is posted on the Texas Department of Health Trauma Registry website: www.tdh.state.tx.us/injury/trauma.htm) It is anticipated that the hospital data dictionary will be effective beginning with January 2000 trauma registry records. i TABLE OF CONTENTS Patient Demographics Diagnosis, Procedures, and Trauma Registry Number……………………... 1 Severity Scores Patient’s Name……………………….………... 1 Diagnoses…………………..………………….. 17 Patient’s Social Security Number………….….. 1 Abbreviated Injury Scale…………..……….…. 17 Facility Number………………………..……… 2 Procedures……………….…………....……….. 17 Medical Record Number………………………. 2 Pre-existing Conditions………………………... 17 Race …………………………………………… 2 Injury Severity Score…………………….……. 18 Gender ……..……….………….…………….. 2 (Body Region) Injury Severity……….……….. 18 Date of Birth…………………………………... 3 (Body Region) Type of Injury…….…………... 18 Date of Injury……….…………..……………... 3 Patient Hospital Cost County of Injury………………..……………… 4 Payor Category……………..………………….. 19 Cause of Injury…………………..…………….. 4 Billed Hospital Charges………….……………. 20 Time of Injury…………………..……………... 4 Total Reimbursement……………….…………. 20 County of Residence…………..………………. 5 Place of Injury…………………..……………... 5 Prehospital Data Respiratory Rate at Scene……………………... 21 Hospital Admission Systolic Blood Pressure at Scene……………… 21 Date of Arrival………………………………… 7 Motor Response at Scene……………………… 22 Time of Arrival………………………………... 7 Verbal Response at Scene……………………... 22 Alcohol Level Tested………………………….. 8 Eye Opening Response at Scene.……..……….. 23 Alcohol Level………………...……………….. 8 Glasgow Coma Score at Scene…………..……. 23 Systolic Blood Pressure…………...…………... 8 Diastolic Blood Pressure………………………. 8 Transport Respiration Rate……………………………….. 9 TDH Firm Number………………….………… 24 Pulse…………………………………………… 9 Time of Dispatch….………………………….... 24 Time of Scene Arrival……….………………… 25 Glasgow Coma Scale at Admission Time of Leaving Scene…………….………….. 25 Motor Response……………………………….. 10 Vehicle Extrication……………….……….…... 26 Verbal Response………………………...…….. 10 Protective Device……………………………… 26 Eye Opening Response……………….……….. 11 Glasgow Coma Score at Admission……...…… 11 Transfer Status Is this a Transfer……………………………….. 27 Revised Trauma Score at Admission First Hospital Number………………………..... 27 Glasgow Coma Score for Revised Trauma Date of Arrival to First Hospital………………. 28 Score…………………………………………... 12 Time of Arrival to First Hospital………...……. 28 Respiratory Rate for Trauma Score………….... 12 Date of Departure from First Hospital………… 29 Systolic Blood Pressure for Trauma Score….… 12 Time of Departure from First Hospital………... 29 Revised Trauma Score……...…………………. 13 Appendices Hospital Discharge Appendix A – Hospital Code List……………... 30 Patient Discharged To………………...……….. 14 Appendix B – EMS Provider Code List………. 36 Condition on Discharge……………..………… 14 Appendix C – County Code List………………. 44 Date of Discharge or Death…………..…….….. 15 Appendix D – City/County Code List………… 45 Time of Discharge or Death…………..……….. 15 Appendix E – Glasgow Coma Score Chart…… 57 Patient Discharged to Facility Number……..…. 16 Appendix F – Diagnosis 1-5 (ICD9CM Coding Length of Stay………………..………...……… 16 Scheme)………………………………………... 58 ICU Length of Stay……………..…………...… 16 Appendix G – Glossary………………………... 60 Appendix H – Data File Creation and Transfer Specifications………………………………….. 61 ii FINAL DRAFT * 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. Length of Field: 1 Type of Field: Character Value Range: None DEFN The initial of the patient’s legal middle name. PATIENT’S SOCIAL SECURITY NUMBER Data Field Number: 5 Data Field Name: SSN Required/Optional: Optional Max. Length of Field: 9 Type of Field: Character Value Range: None DEFN The patient’s social security number. 1 FINAL DRAFT * DATA DICTIONARY PATIENT DEMOGRAPHICS FACILTY NUMBER Data Field Number: 6 Data Field Name: FACILNO Required/Optional: Required Max. Length of Field: 7 Type of Field: Numeric Value Range: 0010001 - 2559999 DEFN The seven digit numeric code assigned to YOUR hospital. Values Facility numbers are assigned by the Texas Department of Health. The list of facility numbers can be found in Appendix A. MEDICAL RECORD NUMBER- Data Field Number: 7 Data Field Name: MEDREC Required/Optional: Optional Max. Length of Field: 15 Type of Field: Character Value Range: None DEFN The medical record number of the patient or any number that uniquely identifies the patient. Values Can be any value as long as the length does not exceed 15 characters. RACE Data Field Number: 8 Data Field Name: RACE Required/Optional: Required Max. Length of Field: 1 Type of Field: Numeric Value Range: 1-6 DEFN The patient's race or ethnic group. Values 1 = White, non-Hispanic 2 = Hispanic 3 = Black 4 = Asian 5 = Native American 6 = Other SEX Data Field Number: 9 Data Field Name: SEX Required/Optional: Required Max. Length of Field: 1 Type of Field: Numeric Value Range: 1-2 DEFN The patient's gender at injury date. If patient is in middle of gender change, use original gender. Values 1 = Male 2 = Female 2 FINAL DRAFT * DATA DICTIONARY PATIENT DEMOGRAPHICS DATE OF BIRTH Data Field Number: 10, 11, 12 Data Field Name: MMOB, DDOB, YYOB Required/Optional: Required Max. Length of Field: 2, 2, 4 Type of Field: Numeric Value Range: [01-12], [0-31], [1880 – present year] DEFN The patient’s date of birth. Estimate, if necessary. Values Month of Birth (MMOB) 01 = January 07 = July 02 = February 08 = August 03 = March 09 = September 04 = April 10 = October 05 = May 11 = November 06 = June 12 = December Day of Birth (DDOB) 0 – 31 Year of Birth (YYOB) Use four-digit year of birth. For example, if the patient was born in 1980, the value would be 1980. DATE OF INJURY Data Field Number: 13, 14, 15 Data Field Name: MMINJ, DDINJ, YYINJ Required/Optional: Required Max. Length of Field: 2, 2, 4 Type of Field: Numeric Value Range: [01-12, 99], [01-31, 99], [2000-present year, 9999] DEFN The date the patient was injured. Values Month of Injury (MMINJ) 01 = January 07 = July 99 = Unknown 02 = February 08 = August 03 = March 09 = September