N.M. Admin. Code § 7.27.7.14

Current through Register Vol. 35, No. 23, December 10, 2024

Section 7.27.7.14 - APPENDIX C: TRAUMA DATA COLLECTION/ DOCUMENTATION CRITERIA

A. Prehospital

(1) scene calls, first responders, licensed ground or certified air ambulance services data shall include:

(a) pre-hospital incident run number

(b) name or name code, when available

(c) date of birth when available

(d) age

(e) sex

(f) social security number when available

(g) agency identification number

(h) first agency on scene (yes/ no)

(i) transporting agency identification

(j) level of transporting agency (BLS/ ALS)

(k) incident county code

(l) date of incident

(m) time

(i) call received

(ii) dispatched

(iii) arrived at scene

(iv) departed scene

(n) initial systolic blood pressure (if obtainable, palpable or best pulse)

(o) respiratory rate

(p) Glasgow coma score- (eye, verbal, and motor when applicable)

(q) narrative description of the mechanism of injury

(r) meets trauma triage criteria (yes/ no)

(s) extrication required

(t) safety restraint or device used

(u) field interventions done

(v) additional information if patient died at scene

(i) patient home zip code

(ii) patient race when available

(2) for interfacility transfers, the transporting service shall include:

(a) agency identification number

(b) pre-hospital run sheet number

(c) inter-facility transfer (yes/ no)

(d) mode of transportation

(e) level of transportation (BLS/ ALS)

(f) patient name or name code

(g) date of birth, when available

(h) social security number, when available

(i) age

(j) sex

(k) agency incident number

(l) name of first hospital

(m) name of receiving hospital

(n) time

(i) depart first hospital

(ii) arrive at receiving facility

B. Designated Trauma Centers

(1) for designated trauma centers, the data shall include:

(a) *indicates a data element currently included in the HTR (Hospital Trauma Registry)

(b) **indicates a data element to be downloaded to the STR (State Trauma Registry)

(c) **identification of facility

(d) **unique patient identification number assigned to the patient by the facility

(e) level of transporting agency (BLS/ALS)

(f) *pre-hospital run sheet number

(g) **date of ED arrival

(h) *time of ED arrival

(i) **date of incident

(j) **initial hospital

(k) **facility patient was transferred from

(2) for designated trauma centers, patient information shall include:

(a) *name or name code

(b) **date of birth

(c) **sex

(d) **race

(e) **patient's trauma identification number (same as b above in section 1)

(f) **social security number

(g) home zip code

(3) **mechanism of injury (narrative)

(4) **E Code, including E Code 849

(5) **occupational injury (yes/ no)

(6) **safety restraint/ device used

(7) time of patient radio report

(8) **trauma team activated (yes/ no)

(9) activation response times

(a) time of activation

(b) time of call to surgeon

(c) *time of arrival of surgeon in ED

(d) *time of arrival of subspecialist

(10) initial vital signs in ED

(a) **systolic blood pressure

(b) **respiratory rate

(c) first temperature

(d) ** Glasgow coma score (eye, verbal, and motor)

(11) **ED respiratory status (spontaneous/ intubated)

(12) **ED procedures performed

(13) *time of ED discharge

(14) **ED discharge disposition

(15) *admitting service

(16) CT scan of head done (yes/ no)

(a) date of head CT scan

(b) time of head CT scan

(17) for initial surgery

(a) **date and time patient arrived or

(b) date/ time operation started

(c) **ICD-9- CM procedure code

(d) *total cc's PRBC infused

(18) **length of primary stay in ICU

(19) *co- morbidity complications

(20) disability at acute care discharge

(a) **feeding

(b) **locomotion

(c) **expression

(d) **rehabilitation potential

(21) **date of facility discharge

(22) **discharge disposition

(23) **extended care facility identification number

(24) autopsy done (yes/ no)

(25) **date of death

(26) **organ/tissue donor (yes/ no)

(27) **final ICD-9 discharge code

(28) *unplanned readmission

(29) **payer source

(30) **total billed charges

C. Office of Medical Investigator- data may include:

(1) name or name code

(2) **date of birth

(3) **social security number

(4) **sex

(5) **race

(6) **date of incident

(7) **date of death

(8) **place of death

(9) home zip code

(10) **medical examiner identification number

(11) **medical examiner facility identification number

(12) **autopsy done

(13) **mechanism of injury

(14) **organ donor

(15) **cause of death

(16) most recent ICD diagnosis code or equivalent description

N.M. Admin. Code § 7.27.7.14

7.27.7.14 NMAC - Rp 7 NMAC 27.7.16, 6/14/02