Root Tag LastModifiedDateTime Patient ID Facility ID The patient’s home ZIP code of primary residence. The country where the patient resides. The patient's home state (territory, province, or District of Columbia) where the patient resides. The patient’s county (or parish) of residence. The patient’s city (or township, or village) of residence. Documentation of the type of patient without a home zip code. The patient's date of birth. The patient's age at the time of injury (best approximation) The units used to document the patient's age (Years, Months, Days, Hours) The patient's race. The patient's ethnicity. The patient's sex. The date the injury occurred. The time the injury occurred. Indication of whether the injury occurred during paid employment. The occupational industry associated with the patient's work environment. The occupation of the patient. E-code used to describe the mechanism (or external factor) that caused the injury event. E-code used to describe the place/site/location of the injury event (E 849.X). Additional E-code used to describe, for example, a mass casualty event, or other external cause. The country where the patient was found or to which the unit responded (or best approximation). The state, territory, or province where the patient was found or to which the unit responded (or best approximation). The county or parish where the patient was found or to which the unit responded (or best approximation). The city or township where the patient was found or to which the unit responded (or best approximation). The ZIP code of the incident location. Protective devices (safety equipment) in use or worn by the patient at the time of the injury. Protective child restraint devices used by patient at the time of injury. Indication of an airbag deployment during a motor vehicle crash. The date the unit transporting to your hospital was notified by dispatch. The time the unit transporting to your hospital was notified by dispatch. The date the unit transporting to your hospital arrived on the scene. The time the unit transporting to your hospital arrived on the scene (the time the vehicle stopped moving). The date the unit transporting to your hospital left the scene. The time the unit transporting to your hospital left the scene (the time the vehicle started moving). The mode of transport delivering the patient to your hospital. All other modes of transport used during patient care event, except the mode delivering the patient to the hospital. First recorded systolic blood pressure in the pre-hospital setting. First recorded pulse in the pre-hospital setting (palpated or auscultated), expressed as a number per minute. First recorded respiratory rate in the pre-hospital setting (expressed as a number per minute). First recorded oxygen saturation in the pre-hospital setting (expressed as a percentage). First recorded Glasgow Coma Score (Eye) in the pre-hospital setting. First recorded Glasgow Coma Score (Verbal) in the pre-hospital setting. First recorded Glasgow Coma Score (Motor) in the pre-hospital setting. First recorded Glasgow Coma Score (total) in the pre-hospital setting. Was the patient transferred to your facility from another acute care facility? The date the patient arrived to the ED/hospital. The time the patient arrived to the ED/hospital. First recorded systolic blood pressure in the ED/Hospital First recorded pulse in the ED/hospital (palpated or auscultated), expressed as a number per minute. First recorded temperature (in degrees celsius/centrigrade) in the ED/hospital. First recorded respiratory rate in the ED/hospital (expressed as a number per minute). Determination of respiratory assistance associated with the initial ED/hospital respiratory rate. First recorded oxygen saturation in the ED/hospital (expressed as a percentage). Determination of the presence of supplemental oxygen during assessment of initial ED/hospital oxygen saturation level. First recorded Glasgow Coma Score (Eye) in the ED/hospital. First recorded Glasgow Coma Score (Verbal) in the ED/hospital. First recorded Glasgow Coma Score (Motor) in the ED/hospital. First recorded Glasgow Coma Score (total) in the ED/hospital. Documentation of factors potentially affecting the first assessment of GCS upon arrival in the ED/hospital. Use of alcohol by the patient. Use of drugs by the patient. The disposition of the patient at the time of discharge from the ED. The type of death incurred while the patient was in the ED. The date the patient was discharged from the ED. The time the patient was discharged from the ED. Operative and essential procedures conducted during hospital stay. The date operative and essential procedures were performed. The time operative and essential procedures were performed. Pre-existing co-morbid factors present before patient arrival at the ED/hospital. Diagnoses related to all identified injuries. The Abbreviated Injury Scale (AIS) predot codes that reflect the patient’s injuries. The Abbreviated Injury Scale (AIS) severity codes that reflect the patient’s injuries. The Injury Severity Score (ISS) body region codes that reflects the patient’s injuries. The software (and version) used to calculate Abbreviated Injury Scale (AIS) severity codes. The Injury Severity Score (ISS) that reflects the patient’s injuries. The total number of patient days in any ICU (including all episodes). The total number of patient days spent on a mechanical ventilator (including all episodes). The date the patient was discharged from the hospital. The time the patient was discharged from the hospital. The disposition of the patient when discharged from the hospital. Primary source of payment for hospital care. Any medical complication that occurred during the patient’s stay at your hospital. The country where the patient resides. The patient's home state (territory, province, or District of Columbia) where the patient resides. The patient's home county (or parish) of residence. The patient's home city (or township, village) of residence. Documentation of the type of patient without a home zip code. Migrant Homeless Foreign Visitor Undocumented Citizen The patient's date of birth. The patient's age at the time of injury (best approximation) The units used to document the patient's age (Years, Months, Days, Hours) Hours Days Months Years The patient's ethnicity. Hispanic or Latino Not Hispanic or Latino The patient's race. Asian Native Hawaiian or Other Pacific Islander Other Race American Indian Black or African American White The patient's sex. Male Female The date the injury occurred. Indication of whether the injury occurred during paid employment. Yes No The occupational industry associated with the patient's work environment. Construction Finance, Insurance, and Real Estate Government Manufacturing Natural Resources and Mining Retail Trade Other Services Transportation and Public Utilities Wholesale Trade Leisure and Hospitality Information Services Agriculture, Forestry, Fishing Professional and Business Services Education and Health Services The occupation of the patient. Management Occupations Business and Financial Operations Occupations Computer and Mathematical Occupations Architecture and Engineering Occupations Life, Physical, and Social Science Occupations Community and Social Services Occupations Legal Occupations Education, Training, and Library Occupations Arts, Design, Entertainment, Sports, and Media Healthcare Practitioners and Technical Occupations Healthcare Support Occupations Protective Service Occupations Food Preparation and Serving Related Building and Grounds Cleaning and Maintenance Personal Care and Service Occupations Sales and Related Occupations Office and Administrative Support Occupations Farming, Fishing, and Forestry Occupations Construction and Extraction Occupations Installation, Maintenance, and Repair Occupations Production Occupations Transportation and Material Moving Occupations Military Specific Occupations E-code used to describe the mechanism (or external factor) that caused the injury event. E-code used to describe the place/site/location of the injury event (E 849.X). Additional E-code used to describe, for example, a mass casualty event, or other external cause. The country where the patient was found or to which the unit responded (or best approximation). The state, territory, or province where the patient was found or to which the unit responded (or best approximation). The county or parish where the patient was found or to which the unit responded (or best approximation). The city or township where the patient was found or to which the unit responded (or best approximation). Protective devices (safety equipment) in use or worn by the patient at the time of the injury. None Child Restraint (booster seat, child car seat) Lap Belt Helmet (eg. Bicycle, Skiing, Motorcycle) Personal Floatation Device Airbag Present Protective Non-Clothing Gear (e.g., shin guard) Protective Clothing (e.g., padded leather pants) Eye Protection Shoulder Belt Other Protective child restraint devices used by patient at the time of injury. Child Car Seat Infant Car Seat Child Booster Seat Indication of an airbag deployment during a motor vehicle crash. Airbag Not Deployed Airbag Deployed Side Airbag Deployed Front Airbag Deployed Other (knee, airbelt, curtain etc) The date the unit transporting to your hospital was notified by dispatch. The date the unit transporting to your hospital arrived on the scene (the time the vehicle stopped moving). The date the unit transporting to your hospital left the scene (the time the vehicle started moving). The mode of transport delivering the patient to your hospital. Private/Public Vehicle/Walk-in Police Other Ground Ambulance Helicopter Ambulance Fixed-wing Ambulance All other modes of transport used during patient care event, except the mode delivering the patient to the hospital. Private/Public Vehicle/Walk-in Police Other Ground Ambulance Helicopter Ambulance Fixed-wing Ambulance First recorded systolic blood pressure in the pre-hospital setting. First recorded pulse in the pre-hospital setting (palpated or auscultated), expressed as a number per minute. First recorded respiratory rate in the prehospital setting (expressed as a number per minute). First recorded oxygen saturation in the pre-hospital setting (expressed as a percentage). First recorded Glasgow Coma Score (Eye) in the pre-hospital setting. No eye movement when assessed Open eyes in response to painful stimulation Opens eyes in response to verbal stimulation Opens eyes spontaneously First recorded Glasgow Coma Score (Verbal) in the pre-hospital setting. Pediatric (≤ 2 years): 1 = No vocal response 2 = Inconsolable, agitated 3 = Inconsistently consolable, moaning 4 = Cries but is consolable, inappropriate interactions 5 = Smiles, oriented to sounds, follows objects, Interacts Adult: 1 = No verbal response 2 = Incomprehensible sounds 3 = Inappropriate words 4 = Confused 5 = Oriented First recorded Glasgow Coma Score (Motor) in the pre-hospital setting. Pediatric (≤ 2 years): 1 = No motor response 2 = Extension to pain 3 = Flexion to pain 4 = Withdrawal from pain 5 = Localizing pain 6 = Appropriate response to stimulation Adult: 1 = No motor response 2 = Extension to pain 3 = Flexion to pain 4 = Withdrawal from pain 5 = Localizing pain 6 = Obeys commands First recorded Glasgow Coma Score (total) in the pre-hospital setting. Was the patient transferred to your facility from another acute care facility? Yes No The date the patient arrived to the ED/Hospital First recorded systolic blood pressure in the ED/hospital. First recorded pulse in the ED/hospital (palpated or auscultated), expressed as a number per minute. First recorded temperature (in degrees celsius/centrigrade) in the ED/hospital. First recorded respiratory rate in the ED/hospital (expressed as a number per minute). Determination of respiratory assistance associated with the initial ED/hospital respiratory rate. Unassisted Respiratory Rate Assisted Respiratory Rate First recorded oxygen saturation in the ED/hospital (expressed as a percentage). Determination of the presence of supplemental oxygen during assessment of initial ED/hospital oxygen saturation level. Supplemental Oxygen No Supplemental Oxygen First recorded Glasgow Coma Score (Eye) in the ED/hospital. No eye movement when assessed Opens eyes in response to verbal stimulation Opens eyes in response to painful stimulation Opens eyes spontaneously First recorded Glasgow Coma Score (Verbal) in the ED/hospital. Pediatric (≤ 2 years): 1 = No vocal response 2 = Inconsolable, agitated 3 = Inconsistently consolable, moaning 4 = Cries but is consolable, inappropriate interactions 5 = Smiles, oriented to sounds, follows objects, Interacts Adult: 1 = No verbal response 2 = Incomprehensible sounds 3 = Inappropriate words 4 = Confused 5 = Oriented First recorded Glasgow Coma Score (Motor) in the ED/hospital. Pediatric (≤ 2 years): 1 = No motor response 2 = Extension to pain 3 = Flexion to pain 4 = Withdrawal from pain 5 = Localizing pain 6 = Appropriate response to stimulation Adult: 1 = No motor response 2 = Extension to pain 3 = Flexion to pain 4 = Withdrawal from pain 5 = Localizing pain 6 = Obeys commands First recorded Glasgow Coma Score (total) in the ED/hospital. Documentation of factors potentially affecting the first assessment of GCS upon arrival in the ED/hospital. Obstruction to the Patient's Eye Patient Chemically Sedated Patient Intubated Use of alcohol by the patient. No (not suspected) No (confirmed by test) Yes (confirmed by test [trace levels) Yes (confirmed by test [beyond legal limit]) Use of drugs by the patient. No (not suspected) Yes (confirmed by test [prescription drug]) No (confirmed by test) Yes (confirmed by test [illegal use drug]) The disposition of the patient at the time of discharge from the ED. Floor bed (general admission, non specialty unit bed) Observation unit (unit that provides < 24 hour stays) Telemetry/step-down unit (less acuity than ICU) Home with services Died Other (jail, institution care facility, mental health, etc) Operating Room Intensive Care Unit (ICU) Home without services Left against medical advice Transferred to another hospital The type of death incurred while the patient was in the ED. DOA: Declared dead on arrival with minimal or no resuscitation attempt Death after failed resuscitation attempt (failure to respond within 15 minutes) Died in ED (other than failed resuscitation attempt) The date the patient was discharged from the ED. Operative and essential procedures conducted during hospital stay. The date operative and essential procedures were performed. The Abbreviated Injury Scale (AIS) predot codes that reflect the patient’s injuries. The Abbreviated Injury Scale (AIS) severity codes that reflect the patient’s injuries. Minor Injury Moderate Injury Serious Injury Severe Injury Critical Injury Maximum Injury, Virtually Unsurvivable The Injury Severity Score (ISS) body region codes that reflects the patient’s injuries. Head or Neck Face Chest Abdominal or pelvic contents Extremities or pelvic girdle External The software (and version) used to calculate Abbreviated Injury Scale (AIS) severity codes. 80 Full code (description and severity, XXXXXX.Y) 85 Full code (description and severity, XXXXXX.Y) 90 Full code (description and severity, XXXXXX.Y) 95 Full code (description and severity, XXXXXX.Y) 98 Full code (description and severity, XXXXXX.Y) 05 Full code (description and severity, XXXXXX.Y) ICD Map Tri-Code AIS80 only (Severity only, .Y) AIS85 only (Severity only, .Y) AIS90 only (Severity only, .Y) AIS95 only (Severity only, .Y) AIS98 only (Severity only, .Y) AIS05 only (Severity only, .Y) Other The Injury Severity Score (ISS) that reflects the patient’s injuries. Diagnoses related to all identified injuries. Pre-existing co-morbid factors present before patient arrival at the ED/hospital. No NTDS co-morbidities are present Alcoholism Ascites within 30 days Bleeding Disorder Chemotherapy for cancer within 30 days Congenital Anomalies Congestive heart failure Current smoker Currently requiring or on dialysis CVA/residual neurological deficit Diabetes mellitus Disseminated cancer Do Not Resuscitate (DNR) status Esophageal varices Functionally dependent health status History of angina within past 1 month History of myocardial infarction within past 6 months History of revascularization / amputation for PVD Hypertension requiring medication Impaired sensorium Prematurity Obesity Respiratory Disease Steroid use The total number of patient days in any ICU (including all episodes). The total number of patient days spent on a mechanical ventilator (including all episodes). The date the patient was discharged from the hospital. The disposition of the patient when discharged from the hospital. Discharged/Transferred to another acute care hospital using EMS Discharged/Transferred to an Intermediate Care Facility Discharge/Transferred to home under care of Home Health Agency Left against medical advice Expired Discharged home with no home services Discharged/Transferred to Skilled Nursing Facility Discharged/Transfered to hospice care Discharged/Transferred to another type of rehabilitation or long term care Primary source of payment for hospital care. Medicaid Not Billed (for any reason) Self Pay Private/Commercial Insurance No Fault Automobile Medicare Other Government Workers Compensation Blue Cross/Blue Shield Other Any medical complication that occurred during the patient’s stay at your hospital. No NTDS listed Medical Complications Occurred Abdominal compartment syndrome Abdominal fascia left open Acute renal failure Acute respiratory distress syndrome (ARDS) Base deficit Bleeding Cardiac arrest with CPR Coagulopathy Coma Decubitus ulcer Deep surgical site infection Drug or alcohol withdrawal syndrome Deep Vein Thrombosis DVT / thrombophlebitis Extremity compartment syndrome Graft/prosthesis/flap failure Intracranial pressure elevation Myocardial infarction Organ/space surgical site infection Pneumonia Pulmonary embolism Stroke / CVA Superficial surgical site infection Systemic sepsis Unplanned intubation Wound disruption Used for times Used for zips Used for blanks/nulls Not Applicable Not Known Not Recorded