The patient's social security number
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, Minutes)
Hours
Days
Months
Years
Minutes
Weeks
The patient's race.
Asian
Native Hawaiian or Other Pacific Islander
Other Race
American Indian
Black or African American
White
The patient's ethnicity.
Hispanic or Latino
Not Hispanic or Latino
The patient's sex.
Male
Female
Non-binary
The occupational industry associated with the patient's work environment.
Finance, Insurance, and Real Estate
Manufacturing
Retail Trade
Transportation and Public Utilities
Agriculture, Forestry, Fishing
Professional and Business Services
Education and Health Services
Construction
Government
Natural Resources and Mining
Information Services
Wholesale Trade
Leisure and Hospitality
Other Services
The occupation of the patient.
Business and Financial Operations Occupations
Architecture and Engineering Occupations
Community and Social Services Occupations
Education, Training, and Library Occupations
Healthcare Practitioners and Technical Occupations
Protective Service Occupations
Building and Grounds Cleaning and Maintenance
Sales and Related Occupations
Farming, Fishing, and Forestry Occupations
Installation, Maintenance, and Repair Occupations
Transportation and Material Moving Occupations
Management Occupations
Computer and Mathematical Occupations
Life, Physical, and Social Science Occupations
Legal Occupations
Arts, Design, Entertainment, Sports, and Media
Healthcare Support Occupations
Food Preparation and Serving Related Occupations
Personal Care and Service Occupations
Office and Administrative Support Occupations
Construction and Extraction Occupations
Production Occupations
Military Specific Occupations
ICD-10 External cause code used to describe the mechanism (or external factor) that caused the injury event.
ICD-10 Place of occurrence external cause code used to describe the place/site/location of the injury event (Y92.X).
The main type of trauma injury sustained by the patient (e.g. blunt, penetrating).
Blunt
Penetrating
Burn
Other
Protective devices (safety equipment) in use or worn by the patient at the time of the injury.
None
Lap Belt
Personal Floatation Device
Protective Non-Clothing Gear (e.g. shin guard)
Eye Protection
Child Restraint (booster seat or child car seat)
Helmet (e.g. bicycle, skiing, motorcycle)
Airbag Present
Protective Clothing (e.g., padded leather pants)
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 Front
Airbag Deployed Side
Airbag Deployed Other (knee, airbelt, curtain etc)
The ID number of the EMS transport agency that delivers the patient to the hospital.
The mode of transport delivering the patient to your hospital.
Ground Ambulance
Helicopter Ambulance
Fixed-Wing Ambulance
Private/Public Vehicle/Walk-In
Police
Other
The patient's universally unique identifier (UUID) as assigned by the emergency medical service (EMS) agency transporting the patient directly from the scene of injury to your hospital.
Physiologic and anatomic EMS trauma triage criteria for transport to a trauma center as defined by the Centers for Disease Control and Prevention and the American College of Surgeons-Committee on Trauma. This information must be found on the scene of injury EMS run sheet.
Glasgow Coma Score <= 13
Systolic Blood Pressure < 90 mmHg
Respiratory Rate <10 or > 29 Breaths per Minute (<20 in Infants Aged <1 Year) or Need for Ventilatory Support
All Penetrating Injuries to Head, Neck, Torso and Extremities Proximal to Elbow or Knee
Chest Wall Instability or Deformity (E.g. Flail Chest)
Two or More Proximal Long-Bone Fractures
Crushed, Degloved, Mangled, or Pulseless Extremity
Amputation Proximal to Wrist or Ankle
Pelvic Fracture
Open or Depressed Skull Fracture
Paralysis
EMS trauma triage mechanism of injury criteria for transport to a trauma center as defined by the Centers for Disease Control and Prevention and the American College of Surgeons-Committee on Trauma. This information must be found on the scene of injury EMS run sheet.
Fall Adults: > 20 ft. (One Story is Equal to 10 ft.)
Fall Children: > 10 ft. or 2-3 Times the Height of the Child
Crash Intrusion, Including Roof: > 12 in. Occupant Site; > 18 in. Any Site
Crash Ejection (Partial or Complete) from Automobile
Crash Death in Same Passenger Compartment
Crash Vehicle Telemetry Data (AACN) Consistent with High Risk Injury
Auto v. Pedestrian/Bicyclist Thrown, Run Over, or > 20 mph Impact
Motorcycle Crash > 20 mph
For Adults > 65; SBP < 110
Patients on Anticoagulants and Bleeding Disorders
Pregnancy > 20 Weeks
EMS Provider Judgment
Burns
Burns with Trauma
The type of death incurred while the patient was in the ED.
Arrived with NO signs of life
Arrived with signs of life
First recorded height upon ED/hospital arrival.
Measured or estimated baseline weight.
First recorded positive drug screen results within 24 hours after first hospital encounter (select all that apply).
AMP (Amphetamine)
BAR (Barbiturate)
BZO (Benzodiazepines)
COC (Cocaine)
mAMP (Methamphetamine)
MDMA (Ecstasy)
MTD (Methadone)
OPI (Opioid)
OXY (Oxycodone)
PCP (Phencyclidine)
TCA (Tricyclic Antidepressant)
THC (Cannabinoid)
Other
None
Not Tested
First recorded blood alcohol concentration (BAC) results within 24 hours after first hospital encounter.
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
Deceased/Expired
Other (Jail, Institutional Care, Mental Health, Etc.)
Operating Room
Intensive Care Unit (ICU)
Home Without Services
Left Against Medical Advice
Transferred to Another Hospital
The weighted Revised Trauma Score (RTS) is a component of the TRISS
Operative and essential procedures conducted during hospital stay.
Any medical complication that occurred during the patient’s stay at your hospital.
Other
Acute Kidney Injury (AKI)
Acute Respiratory Distress Syndrome (ARDS)
Cardiac Arrest With CPR
Deep Surgical Site Infection
Deep Vein Thrombosis (DVT)
Myocardial Infarction (MI)
Organ/Space Surgical Site Infection
Pulmonary Embolism (PE)
Stroke/CVA
Unplanned Intubation
Osteomyelitis
Unplanned Admission to ICU
Severe Sepsis
Catheter-Associated Urinary Tract Infection (CAUTI)
Central Line-Associated Bloodstream Infection (CLABSI)
Ventilator-Associated Pneumonia (VAP)
Alcohol Withdrawal Syndrome
Pressure Ulcer
Superficial Incisional Surgical Site Infection
Delirium
Unplanned Visit to the Operating Room
Pre-existing co-morbid factors present before patient arrival at the ED/hospital.
Other
Alcoholism
Ascites within 30 days
Bleeding Disorder
Currently receiving chemotherapy for cancer
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
Impaired sensorium
Prematurity
Obesity
Respiratory Disease
Steroid use
Cirrhosis
Dementia
Major psychiatric illness
Drug abuse or dependence
Pre-hospital cardiac arrest with CPR
Attention Deficit Disorder/Attention Deficit Hyperactivity Disorder (ADHD)
Anticoagulant Therapy
Angina Pectoris
Mental/Personality Disorders
Myocardial Infarction (MI)
Peripheral Arterial Disease (PAD)
Substance Use Disorder
Prematurity
Pregnancy
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.
Minor Injury
Moderate Injury
Serious Injury
Severe Injury
Critical Injury
Maximum Injury, Virtually Unsurvivable
Not Possible to Assign
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.
AIS 2005, Update 2008
AIS 2015
The Injury Severity Score (ISS) that reflects the patient's injuries.
The Calculated field for estimating the probability of survival
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 disposition of the patient when discharged from the hospital.
Discharged/Transferred to a short-term general hospital for inpatient care
Discharged/Transferred to an Intermediate Care Facility(ICF)
Discharge/Transferred to home under care of organized home health service
Left against medical advice or discontinued care
Deceased/Expired
Discharged to home or self-care (routine discharge)
Discharged/Transferred to Skilled Nursing Facility (SNF)
Discharged/Transferred to hospice care
Discharged/Transferred to court/law enforcement
Discharged/Transferred to inpatient rehab or designated unit
Discharged/Transferred to Long Term Care Hospital (LTCH)
Discharged/Transferred to a psychiatric hospital or psychiatric distinct part unit of a hospital
Discharged/Transferred to another type of institution not defined elsewhere
Primary source of payment for hospital care.
Medicaid
Not Billed (for any reason)
Self Pay
Private/Commercial Insurance
No Fault Automobile
Medicare
Other Government
Other
The National Provider Identifier (NPI) of the admitting surgeon.
Systolic blood pressure
First recorded diastolic blood pressure in the ED/hospital.
Pulse rate (palpated or auscultated), expressed as a number of beats per minute.
First recorded temperature (in degrees celsius/centrigrade) in the ED/hospital.
First recorded temperature (in degrees Fahrenheit) in the ED/hospital.
Respiratory rate (expressed as a number of breaths per minute).
Oxygen saturation or oxygen level, expressed as a percentage or Sp02.
Determination of respiratory assistance associated with the initial ED/hospital respiratory rate.
Unassisted Respiratory Rate
Assisted Respiratory Rate
Determination of the presence of supplemental oxygen during assessment of initial ED/hospital oxygen saturation level.
No Supplemental Oxygen
Supplemental Oxygen
Glasgow Coma Score (Eye)
No Eye Movement When Assessed
Opens Eyes in Response to Painful Stimulation
Opens Eyes in Response to Verbal Stimulation
Opens Eyes Spontaneously
Glasgow Coma Score (Verbal)
(Adult) No Verbal Response (Pediatric) No Vocal Response
(Adult) Incomprehensible Sounds (Pediatric) Inconsolable, Agitated
(Adult) Inappropriate Words (Pediatric) Inconsistently Consolable, Moaning
(Adult) Confused (Pediatric) Cries but is Consolable, Inappropriate Interactions
(Adult) Oriented (Pediatric) Smiles, Oriented to Sounds, Follows Objects, Interacts
Glasgow Coma Score (Motor)
No Motor Response
Extension to Pain
Flexion to Pain
Withdrawal from Pain
Localizing Pain
(Adult) Obeys Commands (Pediatric) Appropriate Response to Stimulation
Glasgow Coma Score (total)
Glasgow Coma Score at 40 (Eye Opening)
Not Testable
None
(Adult) To Pressure (Pediatric) To Pain
To Sound
Spontaneous
Glasgow Coma Score at 40 (Verbal Response)
Not Testable
None
(Adult) Sounds (Pediatric) Cries
(Adult) Words (Pediatric) Vocal Sounds
(Adult) Confused (Pediatric) Words
(Adult) Oriented (Pediatric) Talks Normally
Glasgow Coma Score at 40 (Best Motor Response)
Not Testable
None
(Adult) Extension (Pediatric) Extension to Pain
(Adult) Abnormal Flexion (Pediatric) Flexion to Pain
(Adult) Normal Flexion (Pediatric) Localizes Pain
(Adult) Localizing (Pediatric) Obeys Commands
(Adult) Obeys Commands (Pediatric) Blank
Documentation of factors potentially affecting the first assessment of GCS upon arrival in the ED/hospital.
Patient Chemically Sedated or Paralyzed
Obstruction to the Patient's Eye
Patient Intubated
Valid GCS: Patient Not Sedated, Not Intubated, and Did Not Have Obstruction to Eye
Used for all types of postal codes.
The country where the patient resides or where the incident occured (FIPS code)
The state (territory, province, or District of Columbia) where the patient resides or where the incident occured.(two digit numeric FIPS Code)
The county (or parish) where the patient resides or where the incident occured. (three digit numeric FIPS Code)
The city (or township, village) where the patient resides or where the incident occured. (five digit numeric FIPS Code)
Documentation of the type of patient without a home zip code.
Homeless
Undocumented Citizen
Migrant Worker
Standard date range from January 01, 1990 to January 01, 2030.
Used for times.
Used in many binary choice elements.
Yes
No
Used for blanks/nulls
Not Applicable
Not Known / Not Recorded
Use of alcohol by the patient.
No (not tested)
No (confirmed by test)
Yes (confirmed by test [trace levels])
Yes (confirmed by test [beyond legal limit])
The patient's middle initial