Event. Demographic. Tracking Number: Institute Number: Injury Time: NOT Injury Date: NOT Date Completed: / /
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1 Page 1 Utah Trauma Registry etraumabase Data Abstraction Form Intermountain Injury Control Research Center, University of Utah 295 Chipeta Way, Salt Lake City, UT Trauma Project Coordinator (801) Tracking Number: Institute Number: Injury Time: Injury Date: Date Completed: / / Demographic Date of Birth: / / Age: Age Units: Years Months Weeks Days Sex: Male Female Unknown Race: White Black or African American Asian American Indian Native Hawaiian or Other Pacific Islander Other Race not listed Not Recorded/Not Known Race Other: NA (No secondary race code listed) White Black or African American Asian American Indian Native Hawaiian or Other Pacific Islander Other Race not listed Not Recorded/Not Known Ethnicity: Hispanic or Latino Not Hispanic or Latino Not Applicable Not Recorded/Not Known Patient County: Patient City: Patient State: Patient Zip Code: Patient Country: Alternate Home Status: Homeless Undocumented Citizen Migrant Foreign Visitor NA Medical Record #: SSN: - - Event Injury Country: Injury County: Injury City: Injury State: Injury Zip Code: NA Injury Location: E. or Text: Work Related Incident: No, patient was not working when trauma event occured Yes, patient was working when trauma event occured NA Occupation: NA Business & Financial Operations Architecture & Engineering Community & Social Services Education, Training, Library Healthcare Practitioners & Technical Protective Services Building & Grounds Cleaning & Maintenance Sales Related Farming, Fishing & Forestry Installation, Maintenance & Repair Transportation & Material Moving Management Computer & Mathematics Life, Physical, Social Science Legal Occupations Arts, Design, Entertainment, Sports, Media Healthcare Support Food Preparation & Serving Personal Care & Service Industry Type: NA, not work related Agriculture Business & Professional Services Construction Finance, Insurance & Real Estate Government Health Information Services Manufacturing Mining Recreation, Leisure & Hospitality Retail Trade Transportation & Public Utilities Wholesale Trade Other Protective Devices: NA No personal protection devices used
2 Page 2 Event Continued Airbag Lap Belt/Unspecified Restraint Shoulder Belt (Also select BELT for 3-pt Restraint) Child Restraint Flotation Device Proetective Eyeware Helmet Protective Padding/Clothing Protective Padding Other (i.e shin guard) Other Protective Device Not Listed Airbag Types: Airbag Not Deployed Airbag Deployed Front Airbag Deployed Sige Airbag Deployed Other(knee,airbelt,curtain,etc,) NA Child Restraint Type: Child Car Seat Infant Car Seat Child Booster Seat NA Injury Details: Cause Injury Cause Code: Animal Assault Bicycle Burn Caught Between Objects Diving Explosion Fall(from one level to another or Ground level) Foreign Body Gun Shot Hanging Farm/Heavy Equipment/Power Tools Motorcycle Crash Motor Vehicle Crash Not Known OTHER(not listed) Other Vehicular (includes ATV-3-wheel or 4-wheel) Pedestrian Smoke Inhalation Trauma Type: Blunt (diffuse force) Penetrating(point force) Burn(Electrical, Thermal, Chemical E Code: E Code Description: Co Morbid Co-Morbidities: No Comorbidities Other Comorbidity/Risk Type not listed Alcoholism Ascites within 30 days Bleeding disorder Currently receiving chemotherapy for cancer infarction Congenital anomalies Congestive heart Failure Current smoker Chronic renal failure CVA/ Residual neurological deficit Diabetes mellitus Disseminated cancer Advanced directive limiting care Esophageal varices Functionally dependent health status History of angina within past 1 month History of myocardial infarction History of PVD Hypertension requiring medication R
3 Page 3 Co Morbid Continued Prematurity Obesity Respiratory disease Steroid use Cirrhosis Dementia Major Psychiatric Illness Drug Abuse or Dependence Pre-hospital Cardiac arrest with CPR Not Known/Recorded Pre-hospital Transport EMS Agency: Other EMS Origin: Scene Ref Trans Non Trans Trip Form Received: Yes No NA EMS Dispatch Time: : EMS Dispatch Date: / / EMS En Route Time: : EMS En Route Date: / / EMS Scene Arrival Time: : EMS Scene Arrival Date: / / EMS Scene Departure Time: : EMS Scene Departure Date: / / EMS Destination Arrival Time: : EMS Destination Arrival Date: / / EMS Destination: Referring Transfer from Referring: Not a transfer Yes, this was a hospital transfer Transfer Mode Into Ref Hospital: NA Ground Ambulance Fixed Wing Air Helicopter Law Enforcement (Non-EMS) Commerical Transportation/Taxi POV Referring Hospital Name: Referring Admit Type: NA Admitted to OR as Inpatient ED Care only Referring Arrival Time: : NA Referring Arrival Date: / / NA Referring Discharge Time: : NA Referring Discharge Date: / / NA Arrival/ED Transport Mode To YOUR Hospital: AMB (Ground ambulance) FIX (Fixed wing air) HELI (Helicopter) LAW (Law enforcement, Non-EMS) COM (Commerical/taxi, Non-EMS) POV (Private vehicle, walk-in, bus, Non-EMS) NOT NA Other Transport Modes <check all that apply> Ground ambulance Fixed wing air Helicopter Law enforcement(non-ems) Commerical/taxi(Non-EMS) POV (Private vehicle, walk-in, bus, Non-EMS) NOT NA Hospital Arrival Time: : NA Hospital Arrival Date: / / NA ED Admit Time: : NA ED Admit Date: / / NA ED Discharge Time: : NA ED Discharge Date: / / NA ED Disposition Code: AMA (Against Medical Advice) FLOOR OR OBS ICU
4 Page 4 Arrival/ED Continued TELE HOME with SERVICES HOME without SERVICES Transferred to another hospital OTHER (Jail, Institutional Care, etc.) DOA (minimal or no resuscitation) DEATH in ED (other than failed resuscitation attempt) NA (Patient not seen in ED) ED Transfer Destination Code: NA ED Transfer EMS: NA ED and Inpatient Transfer Reason: Insurance Specialty Care/Higher Level Care Resources Unavailable (Beds, Equipment, Staff, MD) Patient Request Lower Level Care NA Inpatient Hospital Admission Time: : UNK NA Hospital Admit Date: / / UNK NA Admit Service Code: Burn Service Other medical service not listed Neurosurgery Obstetrics Orthopedic Surgery Pediatric Service Psychiatric General Surgery or other surgical services not listed Trauma Service NA Admit Type: Inpatient Admission through the ED Direct Admission Seen in ED then transferred by EMS Seen in ED then transferred by POV Inpatient Discharge Time: : UNK NA Inpatient Discharge Date: / / UNK NA Inpatient Discharge Disposition: NA Hospice Short-term general hospital for inpatient care HOME(no services) HomeHealth Skilled Nursing Facility Rehabilitation Center Hospital Long Term Care Bed Intermediate Care Facility JAIL OTHER Death Left Against Medical Advice Inpatient Transfer Destination Code: NA DC Transfer EMS: NA OUTCOME: ALIVE DEAD TOTAL ICU LOS: NA VENT DAYS: NA Clinical ETOH TESTED: No (not tested) No(confirmed by test) Yes (confirmed by test trace levels) Yes (confirmed by test [beyond legal limit]) NA TOX TESTED: No(not tested) No(confirmed by test) Yes (confirmed by test [Illegal Drug Use]) Yes(confirmed by test [Prescription Drug Use]) NA
5 Page 5 Payment BCBS Blue Cross BlueShield CHIP Childrens Health Insurance Program COM commercial GOVT Government HMO Health Maintenance Organization IHS Indian Health Service LAW Law Enforcement MCAID Medicaid MCARE Medicare NF No Fault Automobile SELF Self Pay WORK Workers Comp OTHER Other payment NA Not Applicable Vital Table REFERRING: NA Location: Time: Date: Pulse Rate: NA Respiratory Rate: NA Respiratory Assistance: NO YES NA Systolic Blood Pressure: NA Eye Opening Response: NA Verbal Reponse: NA Motor Response: NA Glasgow Outcome Score Total: NA GCS Assessment Qualifier: Not Applicable No Qualifiers S Patient Chemically Sedated O Obstruction to the Patient s Eye I Patient Intubated SI Patient chemically sedated and intubated SO Patient chemically sedated and obstruction to the eye SIO Patient chemically sedated, intubated, & obstruction to eye IO Patient intubated and obstruction eye NOT Oxygen Saturation: NA Supplemental Oxygen: NO YES NA Temperature(Celcius): NA FIRST SCENE: NA Location: Time: Date: Pulse Rate: NA Respiratory Rate: NA Respiratory Assistance: NO YES NA Systolic Blood Pressure: NA Eye Opening Response: NA Verbal Reponse: NA Motor Response: NA Glasgow Outcome Score Total: NA GCS Assessment Qualifier: Not Applicable No Qualifiers S Patient Chemically Sedated O Obstruction to the Patient s Eye I Patient Intubated SI Patient chemically sedated and intubated SO Patient chemically sedated and obstruction to the eye SIO Patient chemically sedated, intubated, & obstruction to eye IO Patient intubated and obstruction eye NOT Oxygen Saturation: NA Supplemental Oxygen: NO YES NA Temperature(Celcius): NA FIRST ED: NA Location: Time: Date: Pulse Rate: NA Respiratory Rate: NA
6 Page 6 Vital Table Continued Respiratory Assistance: NO YES NA Systolic Blood Pressure: NA Eye Opening Response: NA Verbal Reponse: NA Motor Response: NA Glasgow Outcome Score Total: NA GCS Assessment Qualifier: Not Applicable No Qualifiers S Patient Chemically Sedated O Obstruction to the Patient s Eye I Patient Intubated SI Patient chemically sedated and intubated SO Patient chemically sedated and obstruction to the eye SIO Patient chemically sedated, intubated, & obstruction to eye IO Patient intubated and obstruction eye NOT Oxygen Saturation: NA Supplemental Oxygen: NO YES NA Temperature(Celcius): NA ICD-9-CM Diagnosis Data ICD-9-CM CODE AIS CODE: DIAGNOSIS REGION (Region of Injury) AIS (Text Description) ABD, ARM, CHEST, CS, EXT, FACE HEAD, LEG, LS, NECK, SPINE, UNK
7 Page 7 Procedure Data CODE LOCATION OR ICD-9-CM RESULT PROCEDURE START TIME/DATE # (Text Description) Complications Not Applicable No Complications Not Known/Not Recorded Acute Respiratory Distress Syndrome Acute kidney injury Catheter-Related Blood Stream Infection Cardiac Arrest with CPR Decubitus ulcer Deep surgical site infection Drug/ alcohol withdrawal syndrome Deep vein thrombosis/ thrombophlebitis Extremity compartment syndrome Graft/ prosthesis/ flap failure Unplanned return to the ICU Unplanned intubation Myocardial infarction Unplanned return to the OR Organ/ space surgical site infection Osteomyelitis Other Complication not listed Pulmonary emobolism Pneumonia Severe Sepsis Stroke or CVA Superficial surgical site infection Urinary Tract Infection
8 Not Applicable No Complications Not Known/Not Recorded Acute Respiratory Distress Syndrome Acute kidney injury Catheter-Related Blood Stream Infection Cardiac Arrest with CPR Decubitus ulcer Deep surgical site infection Drug/ alcohol withdrawal syndrome Deep vein thrombosis/ thrombophlebitis Extremity compartment syndrome Graft/ prosthesis/ flap failure Unplanned return to the ICU Unplanned intubation Myocardial infarction Unplanned return to the OR Organ/ space surgical site infection Osteomyelitis Other Complication not listed Pulmonary emobolism Pneumonia Severe Sepsis Stroke or CVA Superficial surgical site infection Urinary Tract Infection Page 8
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