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