Arizona Administrative Code › Title 9 - HEALTH SERVICES › Chapter 25 - DEPARTMENT OF HEALTH SERVICES - EMERGENCY MEDICAL SERVICES › Article 13 - TRAUMA CENTERS AND TRAUMA REGISTRIES › Section R9-25-1309 - Trauma Registry Data (Authorized by A.R.S.Sections 36-2202(A)(4), 36-2208(A), 36-2209(A)(2), 36-2221, and 36-2225(A)(5) and (6))

Current through Register Vol. 30, No. 28, July 12, 2024
A. A trauma
				registry established according to
				R9-25-1308(B)(1)
				includes the following in the record of a patient's episode of care, as defined
				in A.A.C.
				R9-11-101, for each
				patient meeting the criteria in
				R9-25-1308(C)(1):
1. An identification code specific to the
				health care institution that had contact with the patient during the episode of
				care;
2. Demographic information
				about the patient:
a. The unique number
				assigned by the health care institution to the patient;
b. A code indicating whether the patient's
				record will be submitted to the Department as required in
				R9-25-1308(C)(2);
c. The unique
				number assigned by the health care institution for the episode of
				care;
d. The date the patient
				arrived at the health care institution for the episode of care;
e. For the episode of care, a code indicating
				whether the patient:
i. Was directly admitted
				to the health care institution,
ii.
				Was admitted to the health care institution through the emergency
				department,
iii. Was seen in the
				emergency department then transferred to another health care institution by an
				ambulance service or emergency medical services provider,
iv. Was seen in the emergency department and
				discharged, or
v. Died in the
				emergency department or was dead on arrival;
f. The patient's first name, middle initial,
				and last name;
g. The patient's
				Social Security Number;
h. The
				patient's date of birth and age;
i.
				Codes indicating the patient's gender, race, and ethnicity;
j. The zip code of the patient's residence
				or, if applicable, an indication of why no zip code was reported; and
k. The city, state, and county of the
				patient's residence;
3.
				Information about the occurrence of the patient's injury:
a. The date and time the injury
				occurred;
b. The ICD-code
				describing the type of location where the injury occurred;
c. The zip code of the location where the
				injury occurred;
d. The city,
				state, and county where the injury occurred;
e. A code indicating whether the patient's
				injury resulted from blunt force trauma, a penetrating wound, or a
				burn;
f. The ICD-code indicating
				the primary mechanism or cause of the patient's injury resulting in the episode
				of care and the manner or intent through which the injury occurred;
g. A description of the cause and
				circumstances leading to the patient's injury;
h. Whether the patient was using a protective
				device or safety equipment at the time of the injury and, if so, the type or
				types of protective device or safety equipment being used;
i. If the patient was subject to the
				requirements in A.R.S. §
											28-907
				at the time of the injury, whether the patient was using a child restraint
				system, as defined in A.R.S. §
											28-907,
				at the time of the injury and, if so, the type of child restraint system being
				used; and
j. If the patient's
				injury resulted from a motor vehicle crash, a code describing the status of
				airbag deployment;
4.
				Information about the patient's arrival at the health care institution:
a. A code identifying the mode of
				transportation by which the patient arrived at the health care institution;
				and
b. If applicable:
i. The ambulance service or emergency medical
				services provider that transported the patient to the health care
				institution;
ii. The unique
				identifier given by the ambulance service or emergency medical services
				provider to the incident during which the patient received EMS;
iii. The date the ambulance service or
				emergency medical services provider transported the patient to the trauma
				center; and
iv. If the patient was
				transferred from another health care institution, the name of the other health
				care institution;
5. Information about the health care
				institution's assessment or treatment of the patient in the emergency
				department:
a. A code indicating which of the
				criteria in
				R9-25-1308(C)(1)
				the patient met;
b. A code
				indicating whether an ambulance service or emergency medical services provider
				transported the patient to the health care institution and, if so, the criteria
				used by the transporting ambulance service or emergency medical services
				provider for transporting the patient to the health care institution;
c. The date and time the patient arrived at
				the emergency department of the health care institution for the episode of
				care;
d. The date and time the
				patient died or left the emergency department of the health care institution
				for the episode of care;
e. The
				length of time in hours and in minutes that the patient remained in the
				emergency department of the health care institution during the episode of
				care;
f. If trauma team activation
				occurred, the time when the last trauma team personnel member arrived at their
				assigned location in the health care institution;
g. Whether the patient showed signs of life
				when the patient arrived at the health care institution;
h. The values of the following for the
				patient at the time of their first assessment at the health care institution:
i. Pulse rate;
ii. Respiratory rate;
iii. Oxygen saturation;
iv. Systolic blood pressure; and
v. Temperature, including the units of
				temperature and the route used to measure the patient's temperature;
i. A code indicating whether the
				patient was receiving respiratory assistance at the time the patient's
				respiratory rate was assessed;
j. A
				code indicating whether the patient was receiving supplemental oxygen at the
				time the patient's oxygen saturation was assessed;
k. Codes indicating the Glasgow Coma Score
				for:
i. Eye opening,
ii. Verbal response to stimulus,
				and
iii. Motor response to
				stimulus;
l. The
				patient's total Glasgow Coma Score;
m. Whether the patient was intubated at the
				time of the patient's assessments in subsections (A)(5)(h)(ii), (k)(ii), and
				(l);
n. A code indicating whether a
				paralytic agent or sedative had been administered to the patient at the time
				the patient's Glasgow Coma Score was measured;
o. A code indicating another factor that may
				have affected the patient's Glasgow Coma Score;
p. A revised trauma score for the patient,
				auto-calculated based on the patient's systolic blood pressure, respiratory
				rate, and Glasgow Coma Score;
q. A
				code indicating the status of alcohol use by the patient and, if applicable,
				the blood alcohol concentration in the patient's blood;
r. A code indicating the status of drug use
				by the patient and, if applicable, the code for each drug class detected in the
				patient's blood;
s. A code
				indicating the disposition of the patient at the time the patient was
				discharged from the emergency department; and
t. If the patient was transferred to another
				health care institution upon discharge from the emergency department:
i. The name of the health care institution to
				which the patient was transferred;
ii. The name of the ambulance service or
				emergency medical services provider providing the interfacility
				transport;
iii. A code indicating
				the reason for transfer; and
iv. If
				there was a delay in transferring the patient to another health care
				institution, a code indicating the reason for the delay;
6. Information about the patient's
				discharge from the health care institution:
a. The date and time the patient was
				discharged from the health care institution;
b. The length of time the patient remained as
				an inpatient, as defined in A.A.C.
				R9-10-201, in the
				health care institution;
c. The
				length of time the patient remained in the health care institution's intensive
				care unit;
d. A code indicating
				whether the patient was alive or dead at the time of discharge from the health
				care institution;
e. The ICD-code
				for each injury identified in the patient, including an indication of whether
				the ICD-code is for:
i. The principle
				diagnosis, the reason believed by the health care institution to be chiefly
				responsible for the patient's need for the episode of care; or
ii. A secondary diagnosis, another reason
				believed by the health care institution to have contributed to the patient's
				need for the episode of care;
f. The patient's Injury Severity
				Score;
g. A code indicating the
				disposition of the patient at the time the patient was discharged from the
				health care institution;
h. Whether
				a report of suspected physical abuse was reported to law enforcement or as
				required by A.R.S. §
											13-3620
				or
				46-454,
				if applicable, and, if so:
i. Whether an
				investigation into the suspected physical abuse was initiated by an entity to
				which the suspected physical abuse was reported; and
ii. If the patient is a child, whether the
				patient was discharged in the care of a person other than the person
				responsible for the care of the patient at the time the patient arrived at the
				health care institution; and
i. If the patient was transferred to a
				hospital upon discharge from the health care institution:
i. The name of the hospital to which the
				patient was transferred,
ii. The
				name of the ambulance service or emergency medical services provider providing
				the interfacility transport, and
iii. A code indicating the reason for
				transfer; and
7. Financial information about the episode of
				care:
a. A code for the primary source of
				payment for the episode of care;
b.
				A code for a secondary source of payment for the episode of care, if
				applicable;
c. The total amount of
				charges for the episode of care; and
d. The total amount collected by the health
				care institution for the episode of care.