Definition Unique Admission Number is a number assigned to the trauma patient at your facility. A patient encounter number or account number can be used. NORTN-TACR Data Type xs-idno Element/Domain (Simple Type) IDNo Multiple Configuration No Accepts Null No Required in NORTN-TACR Yes Field Values Relevant for data element Additional Information Use an identifiable number specific to your facility, e.g. patient encounter or account number Data Source Hierarchy 1 Hospital’s trauma registry tracking number DATE EXPORTED Data Format is a date.
Age is simply the patient’s age (or best approximation) at the time of injury. NORTN-TACR Data Type xs-integer NORTN-TACR Element/Domain (Simple Type) Age Multiple Entry Configuration No Accepts Null Value Yes, common null values Required in Yes Minimum Constraint: 0 / Maximum Constraint 120 Field Values Relevant value for data element Additional Information Used to calculate patient age in days, months or years Must also complete variable Age (see next page) Only completed when Date of is “Not Recorded/Not Known” or age is less than 24 hours Data Source Hierarchy ED Admission Form Billing Sheet/Medical Records Coding Summary Sheet EMS Run Sheet Triage Form/Trauma Flow Sheet ED Documentation References to Other Databases NHTSA V.2.2 – E06_14 NTDS 1.2.5 OH-TACR AGE UNITS Data Format is single-choice. Definition Age Units are the units used to document the patient’s age (years, months, days, hours). NORTN-TACR Data Type xs-integer NORTN-TACR Element/Domain (Simple Type) AgeUnits Multiple Entry Configuration No Accepts Null Yes, common null values Required in Yes Field Values Hours
NORTN-TACR Data Type xs- integer NORTN-TACR Element/Domain (Simple Type) Abuse Reported Multiple Entry Configuration No Accepts Null Value Yes, common null values Required in NORTN-TACR Yes Values Yes No Additional Information This includes, but is not limited to, a report of child, elder, spouse or intimate partner physical abuse. Only complete when Report of Physical Abused is Yes The null value “Not Applicable” should be used for patients where Report of Physical Abuse is No. Field should not be blank when Report of Physical Abuse is Yes. Data Source Hierarchy Case Management/Social Service Notes ED Records Progress Notes Discharge Summary History & Physical Nursing Notes/Flow Sheet References to Other Databases NTDS 1.2.5 CAREGIVER AT DISCHARGE Data Format is single-choice. Definition Caregiver at Discharge indicates whether a patient was discharged to a caregiver different than the caregiver at admission due to suspected physical abuse.
References to Other Databases NHTSA V.2.2 – E14_15 NTDS 1.2.5 OTR-TACR INITIAL FIELD GCS - VERBAL Data Format is numeric. Definition Initial Field GCS Verbal Response is the first recorded Glasgow Coma Score verbal assessment done at the scene of injury. NORTN-TACR Data Type xs- integer NORTN-TACR Element/Domain (Simple Type) EMSGcsVerbal Multiple Entry Configuration No Accepts Null Value Yes, common null values Required in NORTN-TACR Yes Minimum Constraint 1 / Maximum Constraint 5 Values Pediatric(<= 2 years of age) 1 No vocal response 1 No verbal response 2 Inconsolable, agitated 2 Incomprehensible sounds 3 Inconsistently consolable, moaning 3 Inappropriate 4 Cries but is consolable, inappropriate interactions 4 Confused 5 Smiles, oriented to sounds, follows objects, interacts 5 Oriented Additional Information Used to calculate Overall GCS – EMS Score If patient is transferred to your facility with no EMS run from the scene of injury, record as Not Known/Not Recorded/Not Documented If a patient does not have a numeric GCS score recorded, but written documentation closely (or directly) relates to verbiage describing a specific level of functioning within the GCS scale, the appropriate numeric score may be listed. E.g. the chart indicates: "patient withdraws from a painful stimulus,” a Motor GCS of 4 may be recorded, IF there is no other contradicting documentation. Data Source Hierarchy EMS Run References to Other Databases NHTSA V.2.2 – E14_16 NTDS 1.2.5
INITIAL FIELD GCS - TOTAL Data Format is numeric. Definition Initial Field Scene GCS Total Score is the first recorded total Glasgow Coma Score done at the scene of injury. NORTN-TACR Data Type xs- integer NORTN-TACR Element/Domain (Simple Type) EMSGcsTotal Multiple Configuration No Accepts Null Value Yes, common null values Required in NORTN-TACR Yes Minimum Constraint 3 / Maximum Constraint 15 Field Values Relevant for data element Additional Information Used to auto-generate an additional calculated field, Revised Trauma Score---EMS (adult & pediatric) If the patient is transferred to your facility with no EMS run sheet from the scene of injury, record as Not Known/Not Recorded/Not Documented If a patient does not have a numeric GCS recorded, but there is documentation related to their level of consciousness such as "AAOx3," "awake alert and oriented," or "patient with normal mental status," interpret this as GCS of 15 IF there is no other contradicting documentation. Data Source Hierarchy EMS Run References to Other Databases NHTSA V.2.2 – E14_19 NTDS 1.2.5 OH-TACR INITAIL GCS QUALIFIER Data Format is multiple-choice. Definition Initial Field GCS Qualifier documents circumstances related to the patient when or near the time that the INITIAL Field Scene GCS Total Score was obtained. NORTN-TACR Data Type xs- integer NORTN-TACR Element/Domain (Simple Type) EMSGcsQualifier Multiple Entry Configuration Yes, 3 Accepts Null Value Yes, common null values
ED DISCHARGE WRITTEN TIME Definition ED Discharge Time is the time that the order was written for the patient to be discharged from your ED. Field Values Relevant for data element Common Null Values Accepted Additional Information If the patient is directly admitted to the hospital, code as NA Data Source Hierarchy Hospital Record Billing Records Coding Summary Sheet Physicians’ Progress Notes References to Databases NTDS 1.2.5 OH-TACR ED DISCHARGE DATE Data Format is a date. Definition ED Discharge Date is the date that the patient was discharged from your ED. NORTN-TACR Data Type xs-date NORTN-TACR Element/Domain (Simple Type) EdDischargeDate Multiple Entry Configuration No Accepts Null Yes, common null values Required in NORTN-TACR Yes Minimum Constraint 1990 /Maximum Constraint 2030 Field Values Relevant for data element
OH-TACR ED DISCHARGE DISPOSITION Data Format is single-choice. Definition ED Discharge Disposition is a general location of where the patient goes at the time of discharge from your ED. NORTN-TACR Data Type xs-integer NORTN-TACR Element/Domain (Simple Type) EdDischargeDispo Multiple Entry Configuration No Accepts Null Value Yes, common null values Required in Yes Field Values 1 bed (general admission, non-specialty unit bed) 7 Operating Room 2 Observation unit 8 Intensive Care Unit (ICU) 3 Telemetry/step-down unit (less acuity than ICU) 9 Home without services 4 Home with services 10 Left against medical advice 5 Died 11 Transferred to another hospital 6 Other (jail, institutional care, mental health, etc.) Additional Information Based upon UB-04 disposition coding If reported as “Died” complete variable of Life If the patient is directly admitted to the hospital, code as NA Data Source Hierarchy Hospital Discharge Summary Nursing Progress Social Worker Notes References to Databases NTDS 1.2.5 OH-TACR ED TRANSFER TO HOSPITAL Data Format is single-choice.
Field Values Relevant value for data element Additional Information Collected as MMDDYYYY This field is linked to the Hospital Procedures Field Data Source Hierarchy Operative Reports Anesthesia Record OR Nurses’ Notes Emergency Department Record EMS Run Report References to Other Databases NTDS 1.2.5 OH-TACR HOSPITAL PROCEDURE START TIME Data Format is numeric. Definition The time operative and essential procedures were performed. NORTN-TACR Data Type xs- time NORTN-TACR Element/Domain (Simple Type) HospProcedureTime Multiple Entry Configuration Yes, 200 Accepts Null Value Yes, common null values Required in NORTN-TACR Yes Values Relevant for data element Additional Information Document as military time Procedure time is defined as the time that the incision was made or that the essential procedure started This is linked to the Hospital Procedures Field Data Source Hierarchy Operative Reports
References to Other Databases NTDS 1.2.5 OH-TACR AIS PRE-DOT CODE Data Format is multiple-choice. Definition AIS Pre-dot Code is a component of the Abbreviated Injury (AIS) code that reflects the patient’s injuries diagnosed at your ED/hospital. NORTN-TACR Data Type xs-string NORTN-TACR Element/Domain (Simple Type) AisPre-dot Multiple Entry Configuration Yes, 50 Accepts Null Value Yes, common null values Required in NORTN-TACR Yes Field Values The pre-dot code is the 6 digits preceding the decimal in an associated AIS code Additional Information Can be utilized to generate Abbreviated Injury and Injury Severity Score Data Source Hierarchy AIS Dictionary References to Other Databases NTDS 1.2.5 OH-TACR AIS SEVERITY Data Format is multiple-choice. Definition AIS Severity is the Abbreviated Injury Scale (AIS) severity codes that reflect the patient’s injuries diagnosed at your ED/hospital. NORTN-TACR Data Type xs-integer Element/Domain (Simple Type) AisSeverity
References to Other Databases NTDS 1.2.5 OH-TACR INJURY SEVERITY Data Format is single-choice. Definition Injury Severity Score (ISS) is a nationally-accepted scoring system that reflects the patient’s injuries for this injury event. NORTN-TACR Data Type xs- integer NORTN-TACR Element/Domain (Simple Type) Iss Multiple Entry Configuration No Accepts Null Value Yes, common null values Required in NORTN-TACR Yes Minimum Constraint 1 / Maximum Constraint 75 Field Values Relevant ISS value for the constellation of injuries Data Source Hierarchy AIS Dictionary References to Other Databases NTDS 1.2.5 OH-TACR ICU LENGTH OF STAY Data Format is numeric. Definition ICU Length of Stay documents the total number of days that the patient spent in any intensive care unit (ICU) (including all episodes) while in your hospital. Data Type xs- integer NORTN-TACR Element/Domain (Simple Type) TotalIcuLos Multiple Configuration No Accepts Null Value Yes, common null values Required in NORTN-TACR Yes Minimum Constraint 0 /Maximum Constraint 400
Inpatient transfer to hospital – added to definition “This includes transfers to inpatient rehabilitation facilities” per OTR dictionary Inpatient transfer to hospital – added to field values “Four- digit hospital code assigned by the Ohio Department of Public Safety” removed “refer to Appendix 1-A for the list of hospital codes” Time of – added to definition “or time of declaration of brain death” per OTR dictionary Primary method of Payment – removed #5 – No fault insurance. Removed additional information pertaining to #5 Hospital Complications – Removed #16, 20, 27 and 28. Added # 33, 34 and 35 This page is intentionally left blank to indicate the end of the dictionary