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PENNSYLVANIA TRAUMA SYSTEMS FOUNDATION ... - ptsf.org

2018. PENNSYLVANIA TRAUMA SYSTEMS FOUNDATION . OPERATIONAL MANUAL FOR THE. DATA BASE COLLECTION SYSTEM. 1. TABLE OF CONTENTS. TOPIC PAGE NUMBER. PREFACE .. 10. GENERAL INSTRUCTIONS .. 12. PTOS PATIENT INCLUSION CRITERIA .. 14. SECTION I: DEMOGRAPHIC DATA .. 18. INSTITUTION 19. ZIP CODE OF RESIDENCE .. 19. RACE .. 19. ETHNICITY .. 20. SEX .. 20. DATE OF BIRTH .. 20. AGE .. 20. PRIMARY ICD-10 MECHANISM (EXTERNAL CAUSE OF MORBIDITY (ICD-10-CM))/ PRIMARY. CAUSE OF INJURY E-CODE (ICD-9) .. 21. PRIMARY CAUSE OF INJURY- External Cause of Morbidity (ICD-10-CM) SPECIFY/(E-CODE. SPECIFY (ICD-9)) .. 21. SECONDARY ICD-10 MECHANISM - External Cause of Morbidity (ICD-10-CM)/(E-CODE (ICD-9)).

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Transcription of PENNSYLVANIA TRAUMA SYSTEMS FOUNDATION ... - ptsf.org

1 2018. PENNSYLVANIA TRAUMA SYSTEMS FOUNDATION . OPERATIONAL MANUAL FOR THE. DATA BASE COLLECTION SYSTEM. 1. TABLE OF CONTENTS. TOPIC PAGE NUMBER. PREFACE .. 10. GENERAL INSTRUCTIONS .. 12. PTOS PATIENT INCLUSION CRITERIA .. 14. SECTION I: DEMOGRAPHIC DATA .. 18. INSTITUTION 19. ZIP CODE OF RESIDENCE .. 19. RACE .. 19. ETHNICITY .. 20. SEX .. 20. DATE OF BIRTH .. 20. AGE .. 20. PRIMARY ICD-10 MECHANISM (EXTERNAL CAUSE OF MORBIDITY (ICD-10-CM))/ PRIMARY. CAUSE OF INJURY E-CODE (ICD-9) .. 21. PRIMARY CAUSE OF INJURY- External Cause of Morbidity (ICD-10-CM) SPECIFY/(E-CODE. SPECIFY (ICD-9)) .. 21. SECONDARY ICD-10 MECHANISM - External Cause of Morbidity (ICD-10-CM)/(E-CODE (ICD-9)).

2 22. HEIGHT OF FALL .. 22. PLACE OF INJURY OF THE EXTERNAL CAUSE (Y92)(ICD-10)/( PLACE OF INJURY E-CODE. ( )(ICD-9) .. 23. PLACE OF INJURY EXTERNAL CAUSE CODE- ICD-10-CM/ E-CODE (ICD-9) SPECIFY .. 23. ACTIVITY E-CODE (OPTIONAL ELEMENT FOR ALL TRAUMA CENTERS) .. 24. INJURY DATE .. 24. INJURY TIME .. 24. COUNTY OF INJURY (STATE IF NOT PA) .. 24. COUNTY OF INJURY (STATE IF NOT PA) IF 24. PROTECTIVE DEVICES .. 25. PRIMARY - TYPE OF 25. SECONDARY -TYPE OF 26. TYPE OF BURN INJURY .. 26. PRE-EXISTING CONDITIONS .. 26. SECTION II: PREHOSPITAL DATA .. 27. SECTION II: PREHOSPITAL DATA .. 28. WAS PATIENT EXTRICATED? .. 28. WERE SCENE PROVIDER AND TRANSPORT PROVIDER THE SAME?)

3 28. ARE ANY SCENE PROVIDER DATA AVAILABLE? .. 28. PROVIDER SCENE AND/OR TRANSPORT .. 30. DATES AND TIMES SCENE AND/OR TRANSPORT .. 30. AMBULANCE SCENE TIME (auto calculation) .. 31. AMBULANCE CODE SCENE AND/OR TRANSPORT .. 31. 2. January 2018 Grey Highlighted area = addition or revision AMBULANCE UNIT NUMBER SCENE AND/OR TRANSPORT .. 31. WAS PATIENT CARE RECORD (PCR) AVAILABLE? SCENE AND/OR TRANSPORT (FLTR 2).. 31. PATIENT CARE RECORD NUMBER SCENE AND/OR 32. LIFE SUPPORT HIGHEST LEVEL OF PROVIDER (SCENE AND/OR TRANSPORT) .. 32. LIFE SUPPORT HIGHEST LEVEL OF CARE (SCENE AND/OR TRANSPORT).. 32. WAS A COMPLETE SET OF VITAL SIGNS (INCLUDING GCS) TAKEN PRIOR TO THE PATIENT.

4 LEAVING THE SCENE OF INJURY? .. 33. PREHOSPITAL VITAL SIGNS SCENE AND/OR TRANSPORT (PULSE RATE/MINUTE) .. 33. PREHOSPITAL VITAL SIGNS SCENE AND/OR TRANSPORT (UNASSISTED RESPIRATORY. RATE/MINUTE) .. 34. PREHOSPITAL VITAL SIGNS SCENE AND/OR TRANSPORT (SYSTOLIC BLOOD PRESSURE).. 34. PREHOSPITAL VITAL SIGNS SCENE AND/OR TRANSPORT (GCS-EYE OPENING) .. 35. PREHOSPITAL VITAL SIGNS SCENE AND/OR TRANSPORT (GCS-VERBAL RESPONSE) .. 35. PREHOSPITAL VITAL SIGNS SCENE AND/OR TRANSPORT (GCS-MOTOR RESPONSE) .. 36. PREHOSPITAL VITAL SIGNS - GCS QUALIFIERS Matches NTDB Initial ED/Hospital GCS. Assessment Qualifiers .. 37. PREHOSPITAL VITAL SIGNS GCS QUALIFIERS PARALYZING DRUGS SPECIFY.

5 38. PREHOSPITAL VITAL SIGNS SCENE AND/OR TRANSPORT (INTUBATED W/ ARTIFICIAL. AIRWAY) .. 38. PREHOSPITAL VITAL SIGNS SCENE AND/OR TRANSPORT - IS PATIENT'S RESPIRATORY RATE. CONTROLLED? (BAGGING OR VENTILATOR) .. 39. PREHOSPITAL VITAL SIGNS SCENE AND/OR TRANSPORT-CONTROLLED RESPIRATORY RATE.. 39. REFERRING FACILITY - IS THIS A TRANSFER PATIENT? .. 39. REFERRING FACILITY IS THERE DATA/INFORMATION AVAILABLE FROM OUTSIDE FACILITY? .. 40. REFERRING FACILITY - DATE AND TIME OF ADMISSION AT REFERRING 40. REFERRING FACILITY - DATE AND TIME OF DISCHARGE FROM REFERRING FACILITY .. 40. REFERRING FACILITY LENGTH OF STAY (Auto Calculation).

6 40. REFERRING FACILITY - DIAGNOSTIC INTERVENTIONS AT REFERRING FACILITY .. 41. REFERRING FACILITY - THERAPEUTIC INTERVENTIONS AT REFERRING FACILITY .. 43. REFERRING FACILITY - REFERRAL FROM FACILITY 44. REFERRING FACILITY UNRESOLVED OCCURRENCES .. 44. REFERRING FACILITY - IS REFERRAL FACILITY CLINICAL DATA AVAILABLE?.. 44. REFERRING FACILITY (PULSE RATE/MINUTE) .. 44. REFERRING FACILITY (UNASSISTED RESPIRATORY RATE/MINUTE) .. 45. REFERRING FACILITY (SYSTOLIC BLOOD PRESSURE) .. 45. REFERRING FACILITY (GCS-EYE OPENING) .. 45. REFERRAL FACILITY (GCS-VERBAL RESPONSE) .. 46. REFERRING FACILITY (GCS-MOTOR RESPONSE).. 47. REFERRING FACILITY - GCS QUALIFIERS - Matches NTDB Initial ED/Hospital GCS.

7 47. Assessment Qualifiers .. 47. REFERRING FACILITY VITAL SIGNS GCS QUALIFIERS PARALYZING DRUGS SPECIFY .. 48. REFERRING FACILITY - INTUBATED WITH ARTIFICIAL AIRWAY .. 48. 3. January 2018 Grey Highlighted area = addition or revision REFERRING FACILITY - IS PATIENT'S RESPIRATORY RATE CONTROLLED? (BAGGING OR. VENTILATOR) .. 49. REFERRING FACILITY-CONTROLLED RESPIRATORY RATE .. 49. REFERRING FACILITY - TEMPERATURE .. 49. REFERRING FACILITY TEMPERATURE ROUTE OF MEASUREMENT .. 49. REFERRING FACILITY WEIGHT AND UNIT OF MEASUREMENT .. 50. REFERRING FACILITY ALCOHOL SCREEN .. 50. REFERRING FACILITY ALCOHOL SCREEN 50. REFERRING FACILITY DRUG SCREEN/(CLINICIAN ADMINISTERED Y/N).

8 51. INTERHOSPITAL - PROVIDER .. 52. INTERHOSPITAL - DATES AND TIMES .. 52. INTERHOSPITAL - AMBULANCE 53. INTERHOSPITAL - AMBULANCE UNIT NUMBER .. 53. INTERHOSPITAL - PATIENT CARE RECORD AVAILABLE? (FILTER 2) .. 53. INTERHOSPITAL - PATIENT CARE RECORD NUMBER .. 53. INTERHOSPITAL - LIFE SUPPORT HIGHEST LEVEL OF 54. INTERHOSPITAL - LIFE SUPPORT HIGHEST LEVEL OF CARE .. 54. INTERHOSPITAL VITAL SIGNS .. 54. INTERHOSPITAL VITAL SIGNS (PULSE RATE/MINUTE) .. 54. INTERHOSPITAL VITAL SIGNS UNASSISTED RESPIRATORY RATE/MINUTE .. 55. INTERHOSPITAL VITAL SIGNS SYSTOLIC BLOOD PRESSURE .. 55. INTERHOSPITAL VITAL SIGNS (GCS-EYE OPENING).

9 55. INTERHOSPITAL VITAL SIGNS (GCS-VERBAL RESPONSE).. 56. INTERHOSPITAL VITAL SIGNS (GCS-MOTOR RESPONSE) .. 57. INTERHOSPITAL VITAL SIGNS - GCS QUALIFIERS - Matches NTDB Initial ED/Hospital GCS .. 57. INTERHOSPITAL VITAL SIGNS GCS QUALIFIERS PARALYZING DRUGS SPECIFY .. 58. INTERHOSPITAL VITAL SIGNS INTUBATED WITH ARTIFICIAL AIRWAY .. 58. INTERHOSPITAL VITAL SIGNS IS PATIENT'S RESPIRATORY RATE CONTROLLED? (BAGGING. OR VENTILATOR) .. 59. INTERHOSPITAL VITAL SIGNS CONTROLLED RESPIRATORY RATE .. 59. SECTION III: PROCESS OF ACUTE CARE .. 60. DATE ENTERED 61. TIME ENTERED ED .. 61. DATE TRANSPORTED TO POST ED DESTINATION .. 61. TIME TRANSPORTED TO POST ED DESTINATION.

10 61. DATE ADMINISTRATIVELY DISCHARGED FROM ED .. 61. TIME ADMINISTRATIVELY DISCHARGED FROM ED .. 62. SIGNS OF LIFE .. 62. POST ED DESTINATION .. 63. TIME OF DECISION TO TRANSFER OUT .. 63. INTERIM ED DISPOSITION-TEMPORARY LOCATION .. 64. TIME FOR REFERRAL (automatic calculation) .. 64. WAS OPERATING ROOM AVAILABLE WHEN PATIENT READY TO TRANSPORT FROM ED TO OR? .. 64. WAS ATTENDING SURGEON PRESENT WHEN THE PATIENT ARRIVED IN THE OR? .. 64. 4. January 2018 Grey Highlighted area = addition or revision IF NO, SPECIFY ARRIVAL TIME .. 65. ATTENDING SURGEON SPECIALTY .. 65. WAS THERE DOCUMENTATION THAT THE ATTENDING ANESTHESIOLOGIST WAS.


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