Mass Trauma Data Instrument - Explanatory Notes

Collect as much of the following information as is feasible to record
and compile in a timely manner. After a mass trauma event, it is
expected that there will be missing data.

**Facility**: Name of entity providing treatment. **Date**: Date when
care was given at the **Time:** Time when care was initiated at

May be a hospital, clinic, or improvised treatment area. facility. Use
MM / DD / YYYY format. the facility. Use military 24-hour clock.

**Last Name**: Family name/surname of patient. **DOB:** Date of Birth.
**Age**: Not necessary if DOB recorded

Include fully hyphenated last names Use MM / DD / YYYY format. Circle
"yrs" (years) or "months".

**First Name**: Given name. **Sex**: Circle "M" if Male; "F" if Female;
"No Data" if sex not known.

**Medical Record \#**: Identification number **Other:** Optional field
that may be used to categorize the patient (e.g. firefighter),

assigned by treating entity. record contact information, or record other
information.

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**Reason for Visit:** Transcribe the patient's reason for seeking
medical care. Reason for visit may be recorded in the chief compliant
section of a medical chart or may be recorded on a disaster logbook or
Emergency Department logbook. Reason for visit may be in the patient's
own words or may be implied or summarized.

**How did the injury happen?** Transcribe as much detail as possible
about *how* the injury happened. Often this information may be recorded
in the history of present illness (HPI) section of the medical chart or
on an ambulance or triage form. (e.g. "glass window shattered on
patient", "tripped while running")

**What was he/she doing?** Transcribe as much detail as possible about
the activity that the patient was doing when injured (e.g. "sitting at
work desk", "walking to school", "searching for other survivors")

**Where did it happen?** Transcribe the most specific information
available about the *place* where the injury occurred (e.g. building
name, street name, vehicle description) and the *location of the
patient* (e.g. floor, room, seat)

**Was the injury caused by the event?** The "event" is an occurrence or
string of occurrences that caused a large number of traumatic injuries.
Based on information available, check the box preceding:

> **Direct Effect**: If the forces of the immediate event caused a
> problem that brought a patient to medical care. (e.g. "cut by
>
> flying glass", "difficulty breathing from smoke")
>
> **Indirect Effect**: If the patient's problem is related to the event
> but not a result of the immediate event forces (e.g. "tripped and fell
> while fleeing", "heart attack while fighting fires",
> "agitation/nervousness after the event").
>
> **Not Event Caused**: If injury is clearly not related to the event.
>
> **No Data**: If it cannot be determined if the injury was caused by
> the event.

**How Patient Arrived**: Check the box next to the appropriate category.
How a patient arrived is often found in the triage notes or Emergency
Department logbook. If no information is available check "No Data".

**Injury Conditions**: Check all injuries that are reported. The most
accurate information on the *nature* of the injury is usually found in
the medical chart, specifically in the section where the attending
physician records the final diagnoses. If a doctor's diagnosis is not
available, look in the nursing notes, ambulance notes, triage notes, or
logbooks. If appropriate and the information is available, record % of
body burned, the degree of the burn (2^nd^ or 3^rd^), or substance that
caused a poisoning. If unsure of appropriate category, choose "Other"
and describe. If no information is available check "No Data".

**Other Conditions:** Check all conditions that are reported. To
determine the presence of other conditions, use the same sources of
information as for determining injury conditions. "Altered mental
status" does not include psychological problems. If unsure of the
appropriate category, choose "Other". (The abbreviation "N/V" stands for
nausea/vomiting.) If unsure of appropriate category, choose "Other" and
describe. If no information is available check "No Data".

**Disposition --** Check the box preceding the description of where the
patient went after assessment and emergency treatment. Check
"Hospitalized" if the patient was admitted to the hospital or observed
in the hospital for \>24 hours. Check "Discharged Home" if the patient
was released from the facility and not hospitalized or transferred.
Check "Left/AMA" if the patient left against medical advice or left
before being discharged. If unsure of the appropriate category, check
"Other" and describe. If no information is available choose "No Data".

**Conditions #1 -- #4:** Transcribe details of patient's injuries or
other conditions. Usually, the most accurate source of details is to
transcribe the doctor's diagnoses directly from the medical chart. If
final diagnoses are not available or do not provide details, look for
information from the physical examination section of the chart, the
results of tests or x-rays, nurses notes, ambulance notes, or logbooks.

**Body Part:** Next to each Condition #1 -- #4, record the part of the
body that is affected. To determine the body part, transcribe
information from the same sources as listed for the details of
conditions. A simplified categorization of body part which may be used
is: head/face/neck, chest, back, abdomen, buttocks/pelvis, arm, or leg.