Trauma Registry Data Dictionary, Lecture notes of Medical Records

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State of Indiana

Trauma Registry

Data Dictionary

Contents

Indiana Inclusion/ExclusionCriteria

Definition:

To ensure consistent data collection across the State and with the National Trauma

Data Standard, a trauma patient is defined as a patient sustaining a traumatic injury

and meeting the following criteria:

The patient must have incurred, no more than 30 days prior to presentation for initial

treatment , at least one of the following injury diagnostic codes defined as follows:

International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-

CM):800– 959.

International Classification of Diseases, Tenth Revision (ICD-10-CM):

S00-S99 with 7th^ character modifiers of A, B, or C ONLY. (Injuries to specific body

parts – initial encounter)

T07 (unspecified multiple injuries)

T14 (injury of unspecified body region)

T20-T28 with 7th^ character modifier of A ONLY (burns by specific body parts – initial

encounter)

T30-T32 (burn by TBSA percentages)

T79.A1-T79.A9 with 7th^ character modifier of A ONLY (Traumatic Compartment

Syndrome – initial encounter)

Excluding the following isolated injuries:

ICD-9-CM:

905-909.9 (late effects of injury)

910-924.9 (superficial injuries: blisters, contusions, abrasions, Insect bites) 930-

939.9 (foreign bodies – ingested, eye, etc.)

ICD-10-CM:

S00 (Superficial injuries of the head)

S10 (Superficial injuries of the neck)

S20 (Superficial injuries of the thorax)

S30 (Superficial injuries of the abdomen, pelvis, lower back and external genitals)

S40 (Superficial injuries of shoulder and upper arm)

S50 (Superficial injuries of elbow and

forearm) S60 (Superficial injuries of wrist,

hand and fingers) S70 (Superficial injuries

of hip and thigh)

S80 (Superficial injuries of knee and lower leg)

S90 (Superficial injuries of ankle, foot, and toes)

Late effect codes, which are represented using the same range of injury diagnosis codes but

with the 7th^ digit modifier code of D through S, are also excluded.

AND MUST INCLUDE ONE OF THE FOLLOWING IN ADDITION TO (ICD-9-CM 800-959.9 OR ICD-

10- CM S00-S99, T07, T14, T20-T28, T30-T32, and T79.A1-T79.A9):

• Hospital admission as defined by your trauma registry inclusion criteria OR:
• Patient transfers via EMS transport (including Air Ambulance) from one hospital to

another hospital (even if later discharged from the ED) OR:

• Death resulting from the traumatic injury (independent of hospital admission or

transfer status)

National & State Element

COMMON NULL VALUES

[combo] single- Data Format choice Definition

These values are to be used with each of the National Trauma Data

Standard Data Elements and Indiana Trauma Data Standard Data Elements

described in this document which have been defined to accept the Null

Values.

Field Values

1 Not Applicable

2 Not Known / Not Recorded

Additional Information

• (^) For any collection of data to be of value and reliably represent what was

intended, a strong commitment must be made to ensure the correct

documentation of incomplete data. When data elements associated with the

National Trauma Data Standard and Indiana Trauma Data Standard are to

be electronically stored in a database or moved from one database to

another using XML, the indicated null values should be applied

• (^) Not Applicable (NA): This null value code applies if, at the time of patient

care documentation, the information requested was "Not Applicable" to the

patient, the hospitalization, or the patient care event. For example, variables

documenting EMS care would be "Not Applicable" if a patient self-transports

to the hospital.

• Not Known / Not Recorded (NK / NR): This null value applies if, at the time

of patient care documentation, information was "Not Known" (to the patient,

family, or health care provider) or no value for the element recorded for the

patient. This documents that there was an attempt to obtain information but

it was unknown by all parties or the information was missing at the time of

documentation. For example, injury date and time may be documented in

the hospital patient care report as "Unknown". Another example, Not

Known/Not Recorded should also be coded when documentation was

expected, but none was provided (i.e., no EMS run sheet in the hospital

record for patient transported by EMS).

Demographic I n f o r m a t i o n