Download NORTN 2016 Data Dictionary - Akron Regional Hospital Association

Northeastern Ohio Regional
Trauma Network
2016
Trauma Acute Care Registry
Data Dictionary
Version 2016.0
Effective for January 1, 2016 admissions
NORTN 2016 Revision
Page 1
Acknowledgements
The NORTN TACR Data Dictionary has been developed according to the OH-TACR which is maintained by
the Ohio Department of Public Safety and the NTDS with is maintained by the National Trauma Data
Bank.
NORTN 2016 Revision
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NORTN Trauma Data Purpose
The purpose of the NORTN Trauma Data is to enhance trauma care and system performance in the Northeast region of
Ohio through collaboration, data-driven performance improvement and coordinated educational programs.
 Analysis of Registry data by NORTN staff, NORTN Data Manager Committee; NORTN Performance Improvement
Committee, vendors, and/or consultants.
NORTN employees, members, and affiliates are bound by Confidentiality Agreements and Provider Agreements with
contributing hospitals. Discussions regarding database contributors will be limited to official registry business. All
individual hospital data is strictly confidential.
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INTERFACE WITH THE STATE TRAUMA REGISTRY
NORTN Registry has incorporated all data elements required by the Ohio Trauma Registry which is housed at the
Division of EMS Ohio Department of Public Safety (ODPS). A few additional data elements have been added to NORTN
Registry in order to gain a more precise picture of trauma specific to Northeast Ohio.
Ohio Hospitals are mandated by Ohio Law to submit trauma data to the State Trauma Registry. The Ohio Revised Code
allows hospitals to submit data to the State of Ohio Trauma Acute Care Registry (TACR) via regional registries such as
NORTN. The NORTN Registry is not responsible to the State of Ohio for data not provided by the individual hospitals to
NORTN. Data submitted to the State of Ohio Trauma Registry will be downloaded through the State’s database by
NORTN personnel.
Although the dictionary shows XML references, the files will be sent from NORTN facilities to the regional database
through CDM proprietary format and then converted into XML when regional information is uploaded to the TACR.
PROVIDING QUALITY DATA
This Data Dictionary is a tool to assist health information abstractors and trauma registrars in interpreting the Data
Elements for NORTN Registry. (The data elements mandated by the State Trauma Registry and the National Trauma
Registry are included in NORTN Registry.) Data abstractors may at times interpret certain data fields differently. Quality
data is dependent upon accurate and consistent abstracting of data elements by all registry participants. Data
abstractors should read this manual in its entirety before beginning data collection.
All abstractors for NORTN Registry should receive an orientation training session before starting data collection. For
tutorial/training related to their computerized trauma registry, call Clinical Data Management, Inc. (CDM), the software
vendor, at the number listed below. Telephone support is available to answer questions or provide additional
clarification as needed.
Northeastern Ohio Regional Trauma Network (NORTN)
Deanah Moore, RHIT – 419-349-3193
Clinical Data Management, Inc. (CDM)
(303) 670-3331
NORTN 2016 Revision
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TIMELINE FOR REPORTING: WHEN IS DATA DUE?
The NORTN Registry should have individual hospital data within 60 days after the end of each quarter. Data should be
reported quarterly based on the patient’s discharge date. For example, if a patient’s discharge date is February 22, this
data should be reported with the 1st quarter data by June 15. Data is needed according to this time frame in order to
prepare it for a quarterly export to the State Registry. Data is sent to the State Registry within 90 days of the conclusion
of each quarter. NORTN downloads data to the State Registry based on the deadlines.
Collection Period
1st Quarter
2nd Quarter
3rd Quarter
4th Quarter
01/01 – 03/31
04/01 – 06/30
07/01 – 09/30
10/01 – 12/31
Submission Date to
NORTN
Submission Deadline to
State of Ohio
06/15
09/15
12/15
03/15
6/30
9/30
12/30
3/30
CONTACTING NORTN REGISTRY
Deanah Moore, RHIT
419-349-3193
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Table of Contents
Submission Date to NORTN ................................................................................................................................................... 5
Submission Deadline to State of Ohio ................................................................................................................................... 5
Northeastern Ohio Regional Trauma Network - Trauma Acute Care Registry (NORTN-TACR) ......................................... 11
NORTN Inclusion/Exclusion Criteria - ICD-10 .......................................................................... Error! Bookmark not defined.
COMMON NULL VALUES ...................................................................................................................................................... 14
HOSPITAL CODE .................................................................................................................................................................... 15
TRAUMA TRACKING NUMBER ............................................................................................................................................. 16
UNIQUE ADMISSION NUMBER ............................................................................................................................................ 17
DATE EXPORTED ................................................................................................................................................................... 18
PATIENT’S HOME CITY .......................................................................................................................................................... 19
PATIENT’S HOME STATE ....................................................................................................................................................... 20
PATIENT’S HOME COUNTY ................................................................................................................................................... 21
PATIENT’S HOME ZIP CODE .................................................................................................................................................. 22
PATIENT’S HOME COUNTRY ................................................................................................................................................. 23
ALTERNATE HOME RESIDENCE............................................................................................................................................. 24
DATE OF BIRTH ..................................................................................................................................................................... 25
AGE........................................................................................................................................................................................ 26
AGE UNITS............................................................................................................................................................................. 27
SEX ........................................................................................................................................................................................ 28
RACE ...................................................................................................................................................................................... 29
ETHNICITY ............................................................................................................................................................................. 30
*CAUSE CODE (NORTN) ........................................................................................................................................................ 31
*INJURY DETAILS(NORTN).................................................................................................................................................... 32
*TRAUMA TYPE (NORTN) ..................................................................................................................................................... 33
PRIMARY ICD-10 EXTERNAL CAUSE CODE ......................................................................................................................... 344
ADDITIONAL ICD-10 EXTERNAL CAUSE CODE.............................................……………….………………………………………………..35
ICD-10 PLACE OF OCCURANCE CODE …………………....…………………………………………….. ……………………………………………………36
WORK-RELATED .................................................................................................................................................................... 37
PATIENT’S OCCUPATIONAL INDUSTRY ................................................................................................................................ 38
PATIENT’S OCCUPATION ...................................................................................................................................................... 39
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INJURY INCIDENT DATE ........................................................................................................................................................ 40
INJURY INCIDENT TIME ........................................................................................................................................................ 41
*INCIDENT STREET ADDRESS (NORTN) ................................................................................................................................ 42
INCIDENT CITY ...................................................................................................................................................................... 43
INCIDENT STATE ................................................................................................................................................................... 44
INCIDENT COUNTY................................................................................................................................................................ 45
INCIDENT LOCATION ZIP CODE ............................................................................................................................................ 46
INCIDENT COUNTRY ............................................................................................................................................................. 47
*EXTRICATION (NORTN)....................................................................................................................................................... 48
PROTECTIVE DEVICES ........................................................................................................................................................... 49
CHILD SPECIFIC RESTRAINT .................................................................................................................................................. 50
AIRBAG DEPLOYMENT.......................................................................................................................................................... 51
REPORT OF PHYSICAL ABUSE (NTDS) ................................................................................................................................. 522
INVESTIGATION OF PHYSICAL ABUSE (NTDS) .................................................................................................................... 533
CAREGIVER AT DISCHARGE (NTDS) .................................................................................................................................... 544
TRANSPORT MODE FOR ARRIVAL AT YOUR HOSPITAL ....................................................................................................... 55
OTHER TRANSPORT MODES............................................................................................................................................... 566
TRANSPORT AGENCY (OTR) ................................................................................................................................................. 57
*SCENE EMS RUN REPORT PRESENT (NORTN) .................................................................................................................... 58
*INTER-FACILITY TRANSFER EMS RUN REPORT PRESENT (NORTN) ................................................................................... 59
EMS DISPATCH DATE TO SCENE OR TRANSFERRING FACILITY ........................................................................................... 60
EMS DISPATCH TIME TO SCENE OR TRANSFERRING FACILITY ............................................................................................ 61
EMS UNIT ARRIVAL DATE AT SCENE OR TRANSFERRING FACILITY ................................................................................... 622
EMS UNIT ARRIVAL TIME FROM SCENE OR TRANSFERRING FACILITY ............................................................................... 63
EMS UNIT DEPARTURE DATE FROM SCENE OR TRANSFERRING FACILITY ......................................................................... 64
EMS UNIT DEPARTURE TIME FROM SCENE OR TRANSFERRING FACILITY .......................................................................... 65
INITIAL FIELD SYSTOLIC BLOOD PRESSURE .......................................................................................................................... 66
INITIAL FIELD PULSE RATE .................................................................................................................................................... 67
INITIAL FIELD RESPIRATORY RATE ....................................................................................................................................... 68
INITIAL FIELD OXYGEN SATURATION ................................................................................................................................... 69
INITIAL FIELD GCS - EYE ........................................................................................................................................................ 70
INITIAL FIELD GCS - VERBAL ................................................................................................................................................. 71
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INITIAL FIELD GCS - MOTOR ............................................................................................................................................... 722
INITIAL FIELD GCS - TOTAL ................................................................................................................................................. 733
INITIAL FIELD GCS QUALIFIER ............................................................................................................................................. 744
SCENE INTERVENTIONS (OTR) ............................................................................................................................................ 755
INTER-FACILITY TRANSFER ................................................................................................................................................. 766
TRANSFERRING HOSPITAL CODE (OTR) ............................................................................................................................... 77
TRAUMA CENTER CRITERIA (NTDS) ................................................................................................................................... 778
VEHICULAR, PEDESTRIAN, OTHER RISK INJURY (NTDS) ................................................................................................... 779
PREHOSPITAL CARDIAC ARREST ........................................................................................................................................ 800
ED/HOSPITAL ARRIVAL DATE ............................................................................................................................................... 81
ED/HOSPITAL ARRIVAL TIME ............................................................................................................................................. 822
TRAUMA ACTIVATION LEVEL (OTR) ................................................................................................................................... 833
*VITAL SIGNS NUMBER (NORTN)....................................................................................................................................... 844
*VITAL SIGNS LOCATION (NORTN) .................................................................................................................................... 855
INITIAL ED/HOSPITAL SYSTOLIC BLOOD PRESSURE .......................................................................................................... 866
INITIAL ED/HOSPITAL PULSE RATE....................................................................................................................................... 87
INITIAL ED/HOSPITAL RESPIRATORY RATE .......................................................................................................................... 88
INITIAL ED/HOSPITAL RESPIRATORY ASSISTANCE ............................................................................................................ 889
INITIAL ED/HOSPITAL OXYGEN SATURATION ..................................................................................................................... 90
INITIAL ED/HOSPITAL SUPPLEMENTAL OXYGEN ................................................................................................................. 91
INITIAL ED/HOSPITAL TEMPERATURE ................................................................................................................................. 92
INITIAL ED/HOSPITAL GCS - EYE ......................................................................................................................................... 933
INITIAL ED/HOSPITAL GCS - VERBAL .................................................................................................................................. 944
INITIAL ED/HOSPITAL GCS - MOTOR.................................................................................................................................. 955
INITIAL ED/HOSPITAL GCS - TOTAL .................................................................................................................................... 966
INITIAL ED/HOSPITAL GCS ASSESSMENT QUALIFIERS......................................................................................................... 97
HEIGHT .................................................................................................................................................................................. 98
WEIGHT ................................................................................................................................................................................. 99
ED DISCHARGE ORDER WRITTEN TIME (OTR) .......................................................................................................... 100
ED DISCHARGE ORDER WRITTEN DATE (OTR) .......................................................................................................... 101
ED DISCHARGE DATE .......................................................................................................................................................... 100
ED DISCHARGE TIME......................................................................................................................................................... 1033
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ED DISCHARGE DISPOSITION ............................................................................................................................................. 104
ED TRANSFER TO HOSPITAL (OTR) ..................................................................................................................................... 105
*DELAY IN TRANSFER (NORTN).......................................................................................................................................... 106
*REASON FOR TRANSFER (NORTN) ................................................................................................................................... 107
COMMENTS ........................................................................................................................................................................ 108
SIGNS OF LIFE ...................................................................................................................................................................... 109
ALCOHOL USE INDICATOR ................................................................................................................................................ 1100
ALCOHOL LEVEL RANGE (OTR) ........................................................................................................................................... 111
DRUG USE INDICATOR...................................................................................................................................................... 1122
*ADMITTING SPECIALTY (NORTN) ................................................................................................................................... 1133
*HOSPITAL PROCEDURE CODE (NORTN) ......................................................................................................................... 1144
PROCEDURE EPISODE (OTR) ............................................................................................................................................. 1177
*PROCEDURE LOCATION (NORTN) .................................................................................................................................. 1188
HOSPITAL PROCEDURES ICD-10 ......................................................................................................................................... 119
HOSPITAL PROCEDURE START DATE ................................................................................................................................ 1200
HOSPITAL PROCEDURE START TIME .................................................................................................................................. 121
CO-MORBID CONDITIONS ................................................................................................................................................ 1222
DNR STATUS ..................................................................................................................................................................... 1233
INJURY DIAGNOSES ICD-10 ................................................................................................................................................ 124
*INJURY DIAGNOSES DESCRIPTION (NORTN) ................................................................................................................... 125
*ISS BODY REGION (NORTN) ............................................................................................................................................ 1266
AIS PRE-DOT CODE ......................................................................................................................................................... 12727
AIS SEVERITY ................................................................................................................................................................... 12828
AIS VERSION ..................................................................................................................................................................... 1299
INJURY SEVERITY SCORE .................................................................................................................................................. 1300
TOTAL ICU LENGTH OF STAY ............................................................................................................................................ 1311
TOTAL VENTILATOR DAYS ................................................................................................................................................ 1332
HOSPITAL DISCHARGE ORDER WRITTEN DATE (OTR) .............................................................................................. 135
HOSPITAL DISCHARGE ORDER WRITTEN TIME (OTR)………………………………………………………………………………………………. 136
HOSPITAL DISCHARGE DATE ............................................................................................................................................ 1357
HOSPITAL DISCHARGE TIME............................................................................................................................................. 1388
HOSPITAL DISCHARGE DISPOSITION.................................................................................................................................. 139
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INPATIENT TRANSFER TO HOSPITAL (OTR) ..................................................................................................................... 1400
LENGTH OF STAY (OTR) .................................................................................................................................................... 1411
DISCHARGE STATUS (OTR) ............................................................................................................................................... 1422
TIME OF DEATH (OTR) ...................................................................................................................................................... 1433
PRIMARY METHOD OF PAYMENT .................................................................................................................................... 1444
*BILLED HOSPITAL CHARGES (NORTN) ............................................................................................................................ 1455
*ORGANS/TISSUE REQUESTED (NORTN) ......................................................................................................................... 1466
AUTOPSY PERFORMED (OTR)........................................................................................................................................... 1477
COMPLICATIONS .................................................................................................................................................... 148
GLOSSARY OF TERMS – DISCHARGE DISPOSITION ........................................................................................................ 14949
GLOSSARY OF TERMS - COMORBID CONDITIONS ............................................................................................................. 150
GLOSSARY OF TERMS - COMPLICATIONS .......................................................................................................................... 154
GLOSSARY OF ABBREVIATIONS.......................................................................................................................................... 163
CHANGE LOG..................................................................................................................................................................... 1634
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Northeastern Ohio Regional Trauma Network - Trauma Acute Care Registry (NORTN-TACR)
TRAUMA PATIENT DEFINITION
In order to ensure consistent data collection within the NORTN region, across the State of Ohio and
following the National Trauma Data Standard, a trauma patient is defined as a patient sustaining a
traumatic injury and meeting the patient inclusion criteria described below.
PATIENT INCLUSION CRITERIA - ICD 10
To be included in the NORTN - Trauma Acute Care Registry (TACR),
1. The patient must incur at least one of the injury diagnostic codes defined in the:
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)
2. The patient MUST ALSO:
 Be admitted for the first time to a hospital or hospital observation unit as defined by a
physician order regardless of the length of stay, with the injury having occurred no more than
30 days prior to arrival; AND/OR

Be transferred via EMS transport (including air ambulance) from one hospital, or free standing
emergency department to another hospital regardless of the patient’s hospital length of stay;
AND/OR

Have an outcome of death resulting from the traumatic injury (independent of hospital
admission or hospital transfer status).
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PATIENT EXCLUSION CRITERIA
Patients with the following isolated ICD-10-CM codes are EXCLUDED from the TACR:
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.
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NORTN TACR Inclusion/Exclusion Decision Tree – ICD-10
Patient with injury less than 30 days ago in the following ICD-10-CM ranges?
S00-S99 (A/B/C 7th dig.), T07, T14, T20-T28 (A 7th dig.), T30-T32 (A 7th dig.), T79.A1-T79.A9 (A 7th dig.)
NO
YES
NO
Was this the first or initial treatment episode for the patient?
YES
Were the patient’s injuries late effects as indicated by ICD-10-CM
7th character modifiers of D through S?
YES
NO
Did the injury result in death?
YES
NO
YES and patient was
not transferred in/out
Did the patient’s ONLY injury ICD-10-CM start with S00, S10, S20, S30,
S40, S50, S60, S70, S80, S90?
NO
OR
YES but transferred in/out
from another hospital, or Free
Standing Emergency Department
Do ANY of the following apply to the patient?
The patient was admitted to your facility (as indicated by a physician order for admit/observation)
The patient was transferred out of your facility, including from the ED, by ground or air ambulance
NO
The patient was transferred into your facility, including direct admit, by ground or air ambulance
YES
INCLUDE in NORTN - TACR
EXCLUDE from NORTN - TACR
NORTN 2016 Revision
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Was the patient transferred to (or from) your hospital via another hospital, or Free Standing Emergency Department using EMS or
air ambulance?
COMMON NULL VALUES
Data Format is single-choice.
Definition
Common Null Values are terms to be used with NORTN-TACR Data Elements as described in this document for
specifically-defined data fields when an answer cannot be provided.
Field Values
NA= Not Applicable
ND= Not Known/Not Recorded/Not Documented
Additional Information

Although not written out on the following pages, these Common Null Values are included in the NORTN-TACR
dataset for every allowable data field. To ascertain their allowability by data field, see the “Accepts Null Value”
notation on every data field descriptor page.

Not Applicable (Field Value NA): This null value code applies if, at any time of patient care documentation, the
information requested was “Not Applicable” (NA) to the patient, the hospitalization or the patient care event.
For example, variables documenting EMS care would be NA if a patient self-transports to the hospital.

Not Known/Not Recorded/Not Documented (Field Value ND): This null value applies if, at the time of patient care
documentation, information was “Not Known” (to the patient, family, healthcare provider) or no value for the
element was 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/Not Documented 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).

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
TACR are be electronically stored in a database or moved from one database to another, the indicated null
values should be applied.
References to Other Databases



Compare with NHTSA V.2.10 – E00
Compare with NTDS V.1.2.5
Compare with OH-TACR
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HOSPITAL CODE
Data Format is numeric.
Definition
Hospital Code is a four-digit (4) hospital code assigned by the Ohio Department of Public Safety.
TACR Data Type
Multiple Entry Configuration
Required in NORTN-TACR
xs-facility
No
Yes
NORTN-TACR Element/Domain (Simple Type)
Accepts Null Value
Facility
No
Field Values

Relevant value for data element
Additional Information

Stored as a four digit code (xxxx)
Data Source Hierarchy

Ohio department of public safety hospital code list
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TRAUMA TRACKING NUMBER
Data Format is numeric.
Definition
Trauma Tracking Number is a sequentially assigned number in the trauma database. This number is individually
assigned and never repeated.
NORTN-TACR Data Type
Multiple Entry Configuration
Required in NORTN-TACR
xs-traumatrack
No
Yes
NORTN-TACR Element/Domain (Simple Type)
Accepts Null Value
TraumaTrack
No
Field Values

Relevant value for data element
Additional Information

This number is individually assigned and never repeated.
Data Source Hierarchy
1
Hospital’s trauma registry tracking number
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UNIQUE ADMISSION NUMBER
Data Format is numeric.
Definition
Unique Admission Number is a number assigned to the trauma patient at your facility. A patient encounter number
or account number can be used.
NORTN-TACR Data Type
Multiple Entry Configuration
Required in NORTN-TACR
xs-idno
No
Yes
NORTN-TACR Element/Domain (Simple Type)
Accepts Null Value
IDNo
No
Field Values

Relevant value for data element
Additional Information

Use an identifiable number specific to your facility, e.g. patient encounter or account number
Data Source Hierarchy
1
Hospital’s trauma registry tracking number
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DATE EXPORTED
Data Format is a date.
Definition
Date Exported is the date the record was submitted to the NORTN-TACR.
NORTN-TACR Data Type
Multiple Entry Configuration
Required in NORTN-TACR
xs-exportdate
No
Yes
NORTN-TACR Element/Domain (Simple Type)
Accepts Null Value
ExportDate
No
Field Values

Relevant value for data element
Additional Information

Collected as MMDDYYYY
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PATIENT’S HOME CITY
Data Format is single-choice.
Definition
Patient’s Home City is the patient’s city, township, or village of residence.
NORTN-TACR Data Type
xs-string
Multiple Entry Configuration
Required in NORTN-TACR
No
Yes
NORTN-TACR Element/Domain (Simple
Type)
Accepts Null Value
HomeCity
Yes, common null values
Field Values

Relevant value for data element
Additional Information

Used to calculate FIPS code
Data Source Hierarchy
1
2
3
4
5
ED Admission Form
Billing Sheet/Medical Records Coding Summary Sheet
EMS Run Sheet
Triage Form/Trauma Flow Sheet
Emergency Department (ED) Documentation
References to Other Databases



NHTSA V.2.2 – E06_05
NTDS 1.2.5
OH-TACR
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PATIENT’S HOME STATE
Data Format is single-choice.
Definition
Patient’s Home State is the state, territory, or province (or the District of Columbia) of the patient’s residence.
NORTN-TACR Data Type
xs-string
Multiple Entry Configuration
Required in NORTN-TACR
No
Yes
NORTN-TACR Element/Domain (Simple
Type)
Accepts Null Value
HomeState
Yes, common null values
Field Values

Relevant value for data element (two digit FIPS code)
Additional Information

Used to calculate FIPS code
Data Source Hierarchy
1
2
3
4
5
ED Admission Form
Billing Sheet/Medical Records Coding Summary Sheet
EMS Run Sheet
Triage Form/Trauma Flow Sheet
ED Documentation
References to Other Databases



NHTSA V.2.2 – E06_07
NTDS 1.2.5
OH-TACR
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PATIENT’S HOME COUNTY
Data Format is single-choice.
Definition
Patient’s Home County is the patient’s county (or parish) of residence.
NORTN-TACR Data Type
xs-string
Multiple Entry Configuration
Required in NORTN-TACR
No
Yes
NORTN-TACR Element/Domain
(Simple Type)
Accepts Null Value
HomeCounty
Yes, common null values
Field Values

Relevant value for data element
Additional Information

Used to calculate FIPS code
Data Source Hierarchy
1
2
3
4
5
ED Admission Form
Billing Sheet/Medical Records Coding Summary Sheet
EMS Run Sheet
Triage Form/Trauma Flow Sheet
ED Documentation
References to Other Databases



NHTSA V.2.2 – E06_06
NTDS 1.2.5
OH-TACR
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PATIENT’S HOME ZIP CODE
Data Format is numeric text.
Definition
Patient’s Home Zip Code is the zip code of the patient’s primary residence.
NORTN-TACR Data Type
xs-zip
Multiple Entry Configuration
Required in NORTN-TACR
No
Yes
NORTN-TACR Element/Domain
(Simple Type)
Accepts Null Value
HomeZip
Yes, common null values
Field Values

Relevant value for data element
Additional Information


Stored as a 5 digit code (XXXXX).
May require adherence to HIPAA regulations.
Data Source Hierarchy
1
2
3
4
5
Billing Sheet/Medical Records Coding Summary Sheet
ED Admission Form
EMS Run Sheet
Triage Form/Trauma Flow Sheet
ED Documentation
References to Other Databases



NHTSA V.2.2 – E06_08
NTDS 1.2.5
OH-TACR
NORTN 2016 Revision
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PATIENT’S HOME COUNTRY
Data Format is single-choice.
Definition
Patient’s Home Country is the country where the patient resides.
NORTN-TACR Data Type
xs-string
Multiple Entry Configuration
Required in NORTN-TACR
No
Yes
NORTNTACR Element/Domain
(Simple Type)
Accepts Null Value
HomeCountry
Yes, common null values
Field Values

Relevant value for data element (two digit alpha country code)
Additional Information

Values are two character fields representing a country (e.g. U.S.)
Data Source Hierarchy
1
2
3
4
5
Billing Sheet/Medical Records Coding Summary Sheet
ED Admission Form
EMS Run Sheet
Triage Form/Trauma Flow Sheet
ED Documentation
References to Other Databases



NHTSA V.2.2 – E06_09
NTDS 1.2.5
OH-TACR
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ALTERNATE HOME RESIDENCE
Data Format is single-choice.
Definition
Alternate Home Residence is documentation of the residential status of a patient who has no home zip code.
NORTN-TACR Data Type
xs-integer
Multiple Entry Configuration
Required in NORTN-TACR
No
Yes
NORTN-TACR Element/Domain
(Simple Type)
Accepts Null Value
HomeResidence
Yes, common null values
Field Values
1
2
3
Homeless
Undocumented Resident
Migrant Worker
Additional Information



Homeless is defined as a person who lacks housing. The definition also includes a person living in transitional
housing or a supervised public or private facility providing temporary living quarters
Undocumented Resident is defined as a national of another country who has entered or stayed in another
country without permission
Migrant Worker is defined as a person who temporarily leaves his/her principal place of residence within a
country in order to accept seasonal employment in the same or different country
Data Source Hierarchy
1
2
3
4
5
Billing Sheet/Medical Records Coding Summary Sheet
ED Admission Form
EMS Run Sheet
Triage Form/Trauma Flow Sheet
ED Documentation
References to Other Databases


NTDS 1.2.5
OH-TACR
NORTN 2016 Revision
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DATE OF BIRTH
Data Format is a date.
Definition
Date of Birth is simply the patient’s date of birth.
NORTN-TACR Data Type
xs-date
Multiple Entry Configuration
Required in NORTN-TACR
No
Yes
NORTN-TACR Element/Domain
DateofBirth
(Simple Type)
Accepts Null Value
Yes, common null values
Minimum Constraint: 1,890 / Maximum Constraint 2,030
Field Values

Relevant value for data element
Additional Information


Collected as MMDDYYYY
If age is known, but the date of birth is not, enter 01/01/YYYY (YYYY appropriate to patient’s known age)
Data Source Hierarchy
1
2
3
4
5
ED Admission Form
Billing Sheet/Medical Records Coding Summary Sheet
EMS Run Sheet
Triage Form/Trauma Flow Sheet
ED Documentation
References to Other Databases



NHTSA V.2.2 – E06_16
NTDS 1.25
OH-TACR
NORTN 2016 Revision
Page 25
AGE
Data Format is numeric.
Definition
Age is simply the patient’s age (or best approximation) at the time of injury.
NORTN-TACR Data Type
xs-integer
Multiple Entry Configuration
Required in NORTN-TACR
No
Yes
NORTN-TACR Element/Domain
Age
(Simple Type)
Accepts Null Value
Yes, common null values
Minimum Constraint: 0 / Maximum Constraint 120
Field Values

Relevant value for data element
Additional Information



Used to calculate patient age in hours, days, months or years
Must also complete variable Age Units (see next page)
Only completed when Date of Birth is “Not Recorded/Not Known” or age is less than 24 hours
Data Source Hierarchy
1
2
3
4
5
ED Admission Form
Billing Sheet/Medical Records Coding Summary Sheet
EMS Run Sheet
Triage Form/Trauma Flow Sheet
ED Documentation
References to Other Databases



NHTSA V.2.2 – E06_14
NTDS 1.2.5
OH-TACR
NORTN 2016 Revision
Page 26
AGE UNITS
Data Format is single-choice.
Definition
Age Units are the units used to document the patient’s age (years, months, days, hours).
NORTN-TACR Data Type
xs-integer
Multiple Entry Configuration
Required in NORTN-TACR
No
Yes
NORTN-TACR Element/Domain
(Simple Type)
Accepts Null Value
AgeUnits
Yes, common null values
Field Values
1
2
3
4
5
Hours
Days
Months
Years
Minutes
Additional Information



Used to calculate patient age in hours, days, months, years or minutes
Must also complete variable Age
Only completed when Date of Birth is “Not Recorded/Not Known” or age is less than 24 hours
Data Source Hierarchy
1
2
3
4
5
ED Admission Form
Billing Sheet/Medical Records Coding Summary Sheet
Triage Form/Trauma Flow Sheet
EMS Run Sheet
ED Documentation
References to Other Databases



NHTSA V.2.2 – E06_15
NTDS 1.2.5
OH-TACR
NORTN 2016 Revision
Page 27
SEX
Data Format is single-choice.
Definition
Sex is the patient’s current gender.
NORTN-TACR Data Type
Multiple Entry Configuration
Required in NORTN-TACR
xs-integer
No
Yes
NORTN-TACR Element/Domain (Simple Type)
Accepts Null Value
Sex
No
Field Values
1 Male
2 Female
Additional Information

Patients who have undergone a surgical and/or hormonal sex change should be coded according to what gender
they state they are. If they are unable to state their gender, they should be coded according to what sex they
appear to be.
Data Source Hierarchy
1
2
3
4
5
ED Admission Form
Billing Sheet/Medical Records Coding Summary Sheet
EMS Run Sheet
Triage Form/Trauma Flow Sheet
ED Documentation
References to Other Databases



NHTSA V.2.2 – E06_11
NTDS 1.2.5
OH-TACR
NORTN 2016 Revision
Page 28
RACE
Data Format is multiple-choice.
Definition
Race is simply the patient’s race.
NORTN-TACR Data Type
xs-integer
Multiple Entry Configuration
Required in NORTN-TACR
No
Yes
NORTN-TACR Element/Domain
(Simple Type)
Accepts Null Value
Race
Yes, common null values
Field Values
1
2
3
4
5
6
Asian
Native Hawaiian or Other Pacific Islander
Other Race
American Indian
Black or African American
White
Additional Information


Patient race should be based upon self-report or identified by a family member
The maximum number of races that may be reported for an individual patient is 2
Data Source Hierarchy
1
2
3
4
5
ED Admission Form
Billing Sheet/Medical Records Coding Summary Sheet
EMS Run Sheet
Triage Form/Trauma Flow Sheet
ED Documentation
References to Other Databases



NHTSA V.2.2 – E06_12
NTDS 1.2.5
OH-TACR
NORTN 2016 Revision
Page 29
ETHNICITY
Data Format is single-choice.
Definition
Ethnicity is the patient’s ethnicity in terms of Hispanic heritage.
NORTN-TACR Data Type
xs-integer
Multiple Entry Configuration
Required in NORTN-TACR
No
Yes
NORTN-TACR Element/Domain
(Simple Type)
Accepts Null Value
Ethnicity
Yes, common null values
Field Values
1
2
Hispanic or Latino
Not Hispanic or Latino
Additional Information


Patient ethnicity should be based upon self-report or identified by a family member
The maximum number of ethnicities that may be reported for an individual patient is 1
Data Source Hierarchy
1
2
3
4
5
ED Admission Form
Billing Sheet/Medical Records Coding Summary Sheet
Triage Form/Trauma Flow Sheet
EMS Run Sheet
ED Documentation
References to Other Databases



NHTSA V.2.2 – E06_13
NTDS 1.2.5
OH-TACR
NORTN 2016 Revision
Page 30
CAUSE CODE
Data Format is single-choice.
Definition
Cause Code is the code for the cause or mechanism of injury.
NORTN-TACR Data Type
xs- integer
Multiple Entry Configuration
Required in NORTN-TACR
No
Yes
NORTN-TACR Element/Domain
(Simple Type)
Accepts Null Value
CAUSE_CODE
No
Field Values
BIKE
BURN
CUT
DROWN
FALL. MINOR
FALL. MAJOR
GSW
MACHINE
MCC
MVC
OTHER
OV
PED
STRUCK
SUFF
Bicycle
Burns (Chemical, Thermal, Electrical)
Cut/ Pierce
Drowning/ Submersion
Fall < 10 feet
Fall > 10 feet
Gun Shot Wound/ Firearm
Machine
Motorcycle Crash
Motor Vehicle Crash
Other
Other Vehicle
Pedestrian
Struck by or against
Suffocation/ Hanging
Additional Information

The Primary E-Code assigned should correlate with the patient’s cause code.
Data Source Hierarchy
1
2
3
4
EMS Run Sheet
Triage Form/Trauma Flow Sheet
ED Documentation
NORTN E-Code Matrix
References to Other Databases
•
NORTN field only
NORTN 2016 Revision
Page 31
INJURY DETAILS
Data Format is free text.
Definition
Injury Details is a free text description that describes the circumstances of how the patient was injured.
NORTN-TACR Data Type
xs-injury_details
Multiple Entry Configuration
Required in NORTN-TACR
No
Yes
NORTN-TACR Element/Domain
(Simple Type)
Accepts Null Value
INJURY_DETAILS
No
Field Values

Relevant value for data element
Additional Information


Include as many details as possible
Examples:
 23- year old male, restrained driver, was T-boned by a tractor-trailer on the driver’s side of the
car, positive LOC
 56- year old female fell down a flight of basement stairs and struck her head on the concrete
floor, denies LOC
Data Source Hierarchy
1 EMS Run Sheet
2 Triage Form/Trauma Flow Sheet
3 ED Documentation
References to Other Databases
•
NORTN field only
NORTN 2016 Revision
Page 32
TRAUMA TYPE
Data Format is single- choice.
Definition
Trauma Type is injury to human tissues or organs resulting from the transfer of energy from the environment to the
human body, in which the human body lacks resilience to resist the energy transference. Trauma refers to critical
injury that threatens life or permanent loss of function of a body part. There are four classifications of trauma, also
referred to as trauma type.
NORTN-TACR Data Type
xs- integer
Multiple Entry Configuration
Required in NORTN-TACR
No
Yes
NORTN-TACR Element/Domain
(Simple Type)
Accepts Null Value
Trauma_Type
No
Field Values
A
B
P
TH
OTHER
Asphyxia
Blunt
Penetrating
Thermal/ Burn/ Cold
Other
Additional Information


See definition under “Glossary of Terms”
Enter the trauma type which causes the highest injury severity
Data Source Hierarchy
1
2
3
4
EMS Run Sheet
Triage Form/Trauma Flow Sheet
ED Documentation
NORTN E-Code Matrix
References to Other Databases
NORTN field only
NORTN 2016 Revision
Page 33
PRIMARY ICD-10 EXTERNAL CAUSE CODE
Data Format is numeric.
Definition
Primary E-Code is a designation used to describe the mechanism (or external factor) that caused the injury event.
NORTN-TACR Data Type
xs-string
Multiple Entry Configuration
Required in NORTN-TACR
No
Yes
NORTN-TACR Element/Domain
(Simple Type)
Accepts Null Value
CAUSE_E_CODES
Yes, common null values
Field Values

Relevant ICD-10-CM code value for injury event
Additional Information



The Primary E-Code should describe the main reason a patient is admitted to the hospital
E-codes can be used to auto-generate the trauma type (blunt, penetrating, burn) and intentionality based upon
the CDC matrix
Activity codes should not be reported in this field
Data Source Hierarchy
1
2
3
4
EMS Run Sheet
Triage Form/Trauma Flow Sheet
Billing Sheet/Medical Records Coding Summary Sheet
ED Documentation
References to Other Databases


NTDS 1.2.5
OH-TACR
NORTN 2016 Revision
Page 34
ADDITIONAL ICD-10 EXTERNAL CAUSE CODE
Data Format is numeric.
Definition
Additional E-code is a designation used to describe, for example, a mass casualty event or other external cause of
injury.
NORTN-TACR Data Type
xs- string
Multiple Entry Configuration
Required in NORTN-TACR
No
Yes
NORTN-TACR Element/Domain
(Simple Type)
Accepts Null Value
CAUSE_E_CODES
Yes, common null values
Field Values

Relevant ICD-10-CM code value for injury event
Additional Information


E-codes can be used to calculate trauma type (blunt, penetrating, burn) and intentionality based upon the CDC
matrix
Activity codes should not be reported in this field
Data Source Hierarchy
5
6
7
8
EMS Run Sheet
Triage Form/Trauma Flow Sheet
Billing Sheet/Medical Records Coding Summary Sheet
ED Documentation
References to Other Databases


NTDS 1.2.5
OH-TACR
NORTN 2016 Revision
Page 35
ICD-10 PLACE OF OCCURRENCE CODE
Data Format is numeric.
Definition
ICD-10 Place of Occurrence code is a Y92.x code used to describe the place, site or location of the injury event.
NORTN-TACR Data Type
xs- integer
Multiple Entry Configuration
Required in NORTN-TACR
No
Yes
NORTN-TACR Element/Domain
(Simple Type)
Accepts Null Value
LocationEcode
Yes, common null values
Field Values

Relevant ICD-10-CM code value for injury event
Additional Information

Some software systems collect the location E-Code has a text value (street, home, etc.) and convert that value
into the appropriate location E-Code during the export of data to the TACR and/ or NTDB
Data Source Hierarchy
1
2
3
4
EMS Run Sheet
Triage Form/Trauma Flow Sheet
Billing Sheet/Medical Records Coding Summary Sheet
ED Documentation
References to Other Databases


NTDS 1.2.5
OTR-TACR
NORTN 2016 Revision
Page 36
WORK-RELATED
Data Format is single-choice.
Definition
Work-related is whether the injury occurred during paid employment.
NORTN-TACR Data Type
xs- integer
Multiple Entry Configuration
Required in NORTN-TACR
No
Yes
NORTN-TACR Element/Domain
(Simple Type)
Accepts Null Value
WorkRelated
Yes, common null values
Field Values
1
2
Yes
No
Additional Information

If work-related, two additional data fields must be completed, Patient’s Occupational Industry and Patient’s
Occupation
Data Source Hierarchy
1
2
3
EMS Run Sheet
Triage Form/Trauma Flow Sheet
ED Documentation
References to Other Databases



NHTSA V.2.2 – E07_15
NTDS 1.2.5
OH-TACR
NORTN 2016 Revision
Page 37
PATIENT’S OCCUPATIONAL INDUSTRY
Data Format is single-choice.
Definition
Patient’s Occupational Industry is the occupational industry associated with the patient’s work environment.
NORTN-TACR Data Type
xs-integer
Multiple Entry Configuration
Required in NORTN-TACR
No
Yes
NORTN-TACR Element/Domain
(Simple Type)
Accepts Null Value
PatientsOccupationalIndustry
Yes, common null values
Field Values
1
2
3
4
5
6
7
Business Finance, Insurance, Real Estate
Manufacturing
Retail Trade
Transportation, Public Utilities
Agriculture, Forestry, Fishing
Professional, Business Services
Education, Health Services
8
9
10
11
12
13
14
Construction
Government
Natural Resources, Mining
Information Services
Wholesale Trade
Leisure, Hospitality
Other Services
Additional Information



Code as NA if injury is not work-related
If work related, also complete Patient’s Occupation
Based upon US Bureau of Labor Statistics Industry Classification
Data Source Hierarchy
1
2
3
Triage Form/Trauma Flow Sheet
EMS Run Sheet
ED Documentation
References to Other Databases



NHTSA V.2.2 – E07_16
NTDS 1.2.5
OH-TACR
NORTN 2016 Revision
Page 38
PATIENT’S OCCUPATION
Data Format is single-choice.
Definition
Patient’s Occupation is simply the patient’s occupation.
NORTN-TACR Data Type
xs- integer
Multiple Entry Configuration
Required in NORTN-TACR
No
Yes
NORTN-TACR Element/Domain
(Simple Type)
Accepts Null Value
PatientsOccupation
Yes, common null values
Field Values
1
2
3
4
5
6
7
8
9
10
11
12
Business, Financial Operations Occupations
Architecture, Engineering Occupations
Community, Social Services Occupations
Education, Training, Library Occupations
Healthcare Practitioners, Technical Occupations
Protective Service Occupations
Building, Grounds Cleaning & Maintenance
Sales & Related Occupations
Farming, Fishing, Forestry Occupations
Installation, Maintenance, Repair Occupations
Transportation, Material Moving Occupations
Management Occupations
13
14
15
16
17
18
19
20
21
22
23
Computer, Mathematical Occupations
Life, Physical, Social Science Occupations
Legal Occupations
Arts, Design, Entertainment, Sports, Media
Healthcare Support Occupations
Food Preparation, Serving Related
Personal Care, Service Occupations
Office, Administrative Support Occupations
Construction, Extraction Occupations
Production Occupations
Military Specific Occupations
Additional Information



Only completed if injury is work-related, otherwise document “NA”
If work related, also complete Patient’s Occupational Industry
Based upon 1999 US Bureau of Labor Statistics Standard Occupational Classification (SOC)
Data Source Hierarchy
1
2
3
Triage Form/Trauma Flow Sheet
EMS Run Sheet
ED Documentation
References to Other Databases



NHTSA V.2.2 – E07_17
NTDS 1.2.5
OH-TACR
NORTN 2016 Revision
Page 39
INJURY INCIDENT DATE
Data Format is a date.
Definition
Injury Incident Date is the date that the injury occurred.
NORTN-TACR Data Type
xs- date
Multiple Entry Configuration
Required in NORTN-TACR
No
Yes
NORTN-TACR Element/Domain (Simple
IncidentDate
Type)
Accepts Null Value
Yes, common null values
Minimum Constraint 1,990 / Maximum Constraint 2,030
Field Values

Relevant value for data element
Additional Information


Collected as MMDDYYYY
Estimates of the date of injury should be based upon report by patient, witness, family or health care provider.
Other proxy measures (e.g. 911 call-time) should NOT be used
Data Source Hierarchy
1
2
3
EMS Run Sheet
Triage Form/Trauma Flow Sheet
ED Documentation
References to Other Databases



NHTSA V.2.2 – E05_01
NTDS 1.2.5
OH-TACR
NORTN 2016 Revision
Page 40
INJURY INCIDENT TIME
Data Format is numeric.
Definition
Injury Incident Time is the time of day that the injury occurred.
NORTN-TACR Data Type
xs- time
Multiple Entry Configuration
Required in NORTN-TACR
No
Yes
NORTN-TACR Element/Domain
(Simple Type)
Accepts Null Value
IncidentTime
Yes, common null values
Field Values

Relevant value for data element
Additional Information


Document as military time
Estimates of time of injury should be based upon report by patient, witness, family, or health care provider.
Other proxy measures (e.g. 911 call-time) should NOT be used
Data Source Hierarchy
1
2
3
EMS Run Sheet
Triage Form/Trauma Flow Sheet
ED Documentation
References to Other Databases



NHTSA V.2.2 – E05_01
NTDS 1.2.5
OH-TACR
NORTN 2016 Revision
Page 41
INCIDENT STREET ADDRESS
Data Format is single-choice.
Definition
Incident Street Address is the exact street location, including street number, in which the injury occurred or to which
the EMS unit responded for the patient.
NORTN-TACR Data Type
xs- string
Multiple Entry Configuration
Required in NORTN-TACR
No
Yes
NORTN-TACR Element/Domain
(Simple Type)
Accepts Null Value
IncidentStreet
Yes, common null values
Field Values

Relevant value for data element
Additional Information


If incident street address is “Unknown” please document “Not Documented”
If the incident occurred at the patients home, put the specific street address of the patients home
Data Source Hierarchy
1
2
3
EMS Run Sheet
Triage Form/Trauma Flow Sheet
ED Documentation
References to Other Databases
•
NORTN field only
NORTN 2016 Revision
Page 42
INCIDENT CITY
Data Format is single-choice.
Definition
Incident City is the city or nearest township in which the injury occurred or to which the EMS unit responded for the
patient.
NORTN-TACR Data Type
xs- string
Multiple Entry Configuration
Required in NORTN-TACR
No
Yes
NORTN-TACR Element/Domain
(Simple Type)
Accepts Null Value
IncidentCity
Yes, common null values
Field Values

Relevant value for data element (five digit FIPS code)
Additional Information


Used to calculate FIPS code
If incident location resides outside of formal city boundaries, report nearest city/town
Data Source Hierarchy
4
5
6
EMS Run Sheet
Triage Form/Trauma Flow Sheet
ED Documentation
References to Other Databases



NHTSA V.2.2 – E08_12
NTDS 1.2.5
OH-TACR
NORTN 2016 Revision
Page 43
INCIDENT STATE
Data Format is single-choice.
Definition
Incident State is the state, territory or province (or best approximation) in which the patient was injured or to which
the EMS unit responded for the patient.
NORTN-TACR Data Type
xs- string
Multiple Entry Configuration
Required in NORTN-TACR
No
Yes
NORTN-TACR Element/Domain
(Simple Type)
Accepts Null Value
IncidentState
Yes, common null values
Field Values

Relevant value for data element (two digit numeric FIPS code)
Additional Information

Used to calculate FIPS code
Data Source Hierarchy
1
2
3
EMS Run Sheet
Triage Form/Trauma Flow Sheet
ED Documentation
References to Other Databases



NHTSA V.2.2 – E08_14
NTDS 1.2.5
OH-TACR
NORTN 2016 Revision
Page 44
INCIDENT COUNTY
Data Format is single-choice.
Definition
Incident County is the county or parish (or best approximation) where the patient was found or to which the EMS
unit responded to the patient.
NORTN-TACR Data Type
xs- string
Multiple Entry Configuration
Required in NORTN-TACR
No
Yes
NORTN-TACR Element/Domain
(Simple Type)
Accepts Null Value
IncidentCount
Yes, common null values
Field Values

Relevant value for data element (three digit FIPS code)
Additional Information

Used to calculate FIPS code
Data Source Hierarchy
1
2
3
EMS Run Sheet
Triage Form/Trauma Flow Sheet
ED Documentation
References to Other Databases



NHTSA V.2.2 – E08_13
NTDS 1.2.5
OH-TACR
NORTN 2016 Revision
Page 45
INCIDENT LOCATION ZIP CODE
Data Format is numeric.
Definition
Incident Location Zip Code is the zip code of the location where the patient was injured.
NORTN-TACR Data Type
xs- zip
Multiple Entry Configuration
Required in NORTN-TACR
No
Yes
NORTN-TACR Element/Domain
(Simple Type)
Accepts Null Value
IncidentZip
Yes, common null values
Field Values

Relevant value for data element
Additional Information


Stored as a five digit code (XXXXX)
May require adherence to HIPAA regulations
Data Source Hierarchy
1
2
3
EMS Run Sheet
Triage Form/Trauma Flow Sheet
ED Documentation
References to Other Databases



NHTSA V.2.2 – E08_15
NTDS 1.2.5
OH-TACR
NORTN 2016 Revision
Page 46
INCIDENT COUNTRY
Data Format is single-choice.
Definition
Incident Country is the country (or best approximation) in which the patient was injured or to which the EMS unit
responded to the patient.
NORTN-TACR Data Type
xs- string
Multiple Entry Configuration
Required in NORTN-TACR
No
Yes
NORTN-TACR Element/Domain
(Simple Type)
Accepts Null Value
IncidentCountry
Yes, common null values
Field Values

Relevant value for data element (two digit alpha country code)
Additional Information

Values are two character fields representing a country (e.g. US)
Data Source Hierarchy
1
2
3
4
EMS Run Sheet
Triage Form/Trauma Flow Sheet
ED Documentation
Medical Records
References to Other Databases


NTDS 1.2.5
OH-TACR
NORTN 2016 Revision
Page 47
EXTRICATION
Data Format is single-choice.
Definition
Extrication is if the patient was entrapped and required extrication (i.e. vehicle, building, trench, etc).
NORTN-TACR Data Type
xs- integer
Multiple Entry Configuration
Required in NORTN-TACR
No
Yes
NORTN-TACR Element/Domain
(Simple Type)
Accepts Null Value
Extrication
Yes, common null values
Field Values
N
Y
ND
NA
No, patient was not extricated
Yes, patient was extricated
Not Documented
Not Applicable
Additional Information



The “Jaws of Life” was used to extricate a patient from a vehicle, building or other confined structure
Debris was moved off the patient
Patient was placed in a safety basket and air lifted out of a flooded stream or deep trench
Data Source Hierarchy
1
2
3
4
EMS Run Sheet
Triage Form/Trauma Flow Sheet
ED Documentation
Medical Records
References to Other Databases
•
NORTN field only
NORTN 2016 Revision
Page 48
PROTECTIVE DEVICES
Data Format is multiple-choice.
Definition
Protective Devices is the safety equipment in use or worn by the patient at the time of the injury.
NORTN-TACR Data Type
xs- integer
Multiple Entry Configuration
Required in NORTN-TACR
Yes, max 10
Yes
NORTN-TACR Element/Domain
(Simple Type)
Accepts Null Value
ProtectiveDevice
Yes, common null values
Field Values
1
2
3
4
5
6
None Used
Lap Belt
Personal Floatation Device
Protective Non-Clothing Gear (e.g. shin guard)
Eye Protection
Child Restraint (booster seat, child car seat)
7
8
9
10
11
Helmet (e.g., bicycle, skiing, motorcycle)
Airbag Present
Protective Clothing (e.g. padded leather pants)
Shoulder Belt
Other
Additional Information






Check all that apply
If “Child Restraint” is present, complete variable Child Specific Restraint
If “Airbag” is present, complete variable Airbag Deployment
Evidence of the use of safety equipment may be reported or observed
“Lap belt” should be used to include those patients that are restrained, but not further specified
If chart indicates three- point restraint, choose field values #2 and 10
Data Source Hierarchy
5
6
7
8
EMS Run Sheet
Triage Form/Trauma Flow Sheet
ED Documentation
Medical Records
References to Other Databases



NHTSA V.2.2 – E10_08
NTDS 1.2.5
OH-TACR
NORTN 2016 Revision
Page 49
CHILD SPECIFIC RESTRAINT
Data Format is single-choice.
Definition
Child Specific Restraint indicates protective child restraint devices used by the pediatric patient at the time of injury.
NORTN-TACR Data Type
xs- integer
Multiple Entry Configuration
Required in NORTN-TACR
No
Yes
NORTN-TACR Element/Domain
(Simple Type)
Accepts Null Value
ChildSpecificRestraint
Yes, common null values
Field Values
1
2
3
Child Car Seat
Infant Car Seat
Child Booster Seat
Additional Information


Evidence of the use of child restraint may be reported or observed
Only completed when Protective Devices include “Child Restraint”
Data Source Hierarchy
1
2
3
4
EMS Run Sheet
Triage Form/Trauma Flow Sheet
ED Documentation
Medical Records
References to Other Databases


NTDS 1.2.5
OH-TACR
NORTN 2016 Revision
Page 50
AIRBAG DEPLOYMENT
Data Format is multiple-choice.
Definition
Airbag Deployment indicates whether an airbag deployed during a motor vehicle crash.
NORTN-TACR Data Type
xs- integer
Multiple Entry Configuration
Required in NORTN-TACR
Yes, max 4
Yes
NORTN-TACR Element/Domain
(Simple Type)
Accepts Null Value
Airbag Deployment
Yes, common null values
Field Values
1
2
3
4
Airbag Not Deployed
Airbag Deployed Front
Airbag Deployed Side
Airbag Deployed Other (knee, airbelt, curtain, etc)
Additional Information




Airbag Deployed Front should be used for patients with airbag deployment documented in the medical record
when the site of the airbag is not further specified.
Check all that apply
Evidence of the use of airbag deployment may be reported or observed
Only completed when Protective Devices include “Airbag”
Data Source Hierarchy
1
2
3
4
EMS Run Sheet
Triage Form/Trauma Flow Sheet
ED Documentation
Medical Records
References to Other Databases



NHTSA V.2.2 – E10_09
NTDS 1.2.5
OH-TACR
NORTN 2016 Revision
Page 51
REPORT OF PHYSICAL ABUSE
Data Format is single-choice.
Definition
Report of Physical Abuse indicates whether a report of physical abuse was made to law enforcement and/or
protective services.
NORTN-TACR Data Type
xs- integer
Multiple Entry Configuration
Required in NORTN-TACR
No
Yes
NORTN-TACR Element/Domain
(Simple Type)
Accepts Null Value
Abuse Reported
No
Field Values
1. Yes
2. No
Additional Information


This includes, but is not limited to, a report of child, elder, spouse or intimate partner physical abuse.
Field cannot be Not Applicable
Data Source Hierarchy
1.
2.
3.
4.
5.
6.
7.
Case Management/Social Service Notes
ED Records
Progress Notes
Discharge Summary
History & Physical
Nursing Notes/Flow Sheet
EMS Run Report
References to Other Databases

NTDS 1.2.5
NORTN 2016 Revision
Page 52
INVESTIGATION OF PHYSICAL ABUSE
Data Format is single-choice.
Definition
Investigation of Physical Abuse indicates whether an investigation by law enforcement and/or protective services
was initiated because of the suspected physical abuse.
NORTN-TACR Data Type
xs- integer
Multiple Entry Configuration
Required in NORTN-TACR
No
Yes
NORTN-TACR Element/Domain
(Simple Type)
Accepts Null Value
Abuse Reported
Yes, common null values
Field Values
1. Yes
2. No
Additional Information




This includes, but is not limited to, a report of child, elder, spouse or intimate partner physical abuse.
Only complete when Report of Physical Abused is Yes
The null value “Not Applicable” should be used for patients where Report of Physical Abuse is No.
Field should not be blank when Report of Physical Abuse is Yes.
Data Source Hierarchy
1.
2.
3.
4.
5.
6.
Case Management/Social Service Notes
ED Records
Progress Notes
Discharge Summary
History & Physical
Nursing Notes/Flow Sheet
References to Other Databases

NTDS 1.2.5
NORTN 2016 Revision
Page 53
CAREGIVER AT DISCHARGE
Data Format is single-choice.
Definition
Caregiver at Discharge indicates whether a patient was discharged to a caregiver different than the caregiver at
admission due to suspected physical abuse.
NORTN-TACR Data Type
xs- integer
Multiple Entry Configuration
Required in NORTN-TACR
No
Yes
NORTN-TACR Element/Domain
(Simple Type)
Accepts Null Value
Abuse Reported
Yes, common null values
Field Values
1. Yes
2. No
Additional Information





Only complete when Report of Physical Abused is Yes
Only complete for minors as determined by state/local definition, excluding emancipated minors
The null value “Not Applicable” should be used for patients where Report of Physical Abuse is No or where older
than the state/local age definition of a minor.
The null value “Not Applicable” should be used if the patient expires prior to discharge.
Field should not be blank when Report of Physical Abuse is Yes.
Data Source Hierarchy
1.
2.
3.
4.
Case Management/Social Service Notes
Discharge Summary
Nursing Notes/Flow Sheet
Progress Notes
References to Other Databases

NTDS 1.2.5
NORTN 2016 Revision
Page 54
TRANSPORT MODE FOR ARRIVAL AT YOUR HOSPITAL
Data Format is single-choice.
Definition
Transport Mode for Arrival at Your Hospital is the manner of transport delivering the patient to your hospital.
NORTN-TACR Data Type
xs- integer
Multiple Entry Configuration
Required in NORTN-TACR
No
Yes
NORTN-TACR Element/Domain
(Simple Type)
Accepts Null Value
TransportMode
Yes, common null values
Field Values
1
2
3
4
5
6
Ground Ambulance
Helicopter Ambulance
Fixed-wing Ambulance
Private or Public Vehicle or Walk-in
Police Transport
Other Transport Mode
Data Source Hierarchy


EMS Run Sheet
ED Record
References to Other Databases


NTDS 1.2.5
OH-TACR
NORTN 2016 Revision
Page 55
OTHER TRANSPORT MODES
Data Format is multiple-choice.
Definition
Other Transport Modes documents all other types of transport used during patient care prior to the patient arriving
at your hospital, except the transport mode delivering the patient to your hospital. An example is an ambulance
transporting the patient to the helicopter landing zone.
NORTN-TACR Data Type
xs- integer
Multiple Entry Configuration
Required in NORTN-TACR
Yes, 5
Yes
NORTN-TACR Element/Domain
(Simple Type)
Accepts Null Value
OtherTransportMode
Yes, common null values
Field Values
1
2
3
4
5
6
Ground Ambulance
Helicopter Ambulance
Fixed-wing Ambulance
Private or Public Vehicle or Walk-in
Police Transport
Other Transport Mode
Additional Information


For patients with an unspecified mode of transport, select 6, Other
“Non-applicable” (NA) is used to indicate that a patient had a single mode of transport and therefore this field
does not apply to the patient
Data Source Hierarchy
1
2
EMS Run Sheet
ED Record
References to Other Databases


NTDS 1.2.5
OH-TACR
NORTN 2016 Revision
Page 56
TRANSPORT AGENCY
Data Format is single-choice.
Definition
Transport Agency is the name of the EMS unit that transported the patient to your facility.
NORTN-TACR Data Type
xs- integer
Multiple Entry Configuration
Required in NORTN-TACR
No
Yes
NORTN-TACR Element/Domain
(Simple Type)
Accepts Null Value
TransportAgency
Yes, common null values
Field Values

Refer to Appendix 2-A for the ODPS list of agency codes.
Additional Information

“Non-applicable” (NA) is used to indicate that a patient arrived via “Private or Public Vehicle or Walk-in,” “Police
Transport,” or “Other Transport Mode”
Data Source Hierarchy
1. EMS Run Sheet
2. ED Record
References to Other Databases
 OH-TACR (Not NTDS field)
NORTN 2016 Revision
Page 57
SCENE EMS RUN REPORT PRESENT
Data Format is single-choice.
Definition
Scene EMS Run Report Present documents whether the run report generated by EMS at the injury scene is found in
the patient’s medical record.
 For patients transported from the scene of injury to your hospital, this is the run report transporting the patient
to your facility from the scene.
NORTN-TACR Data Type
xs- integer
Multiple Entry Configuration
Required in NORTN-TACR
No
Yes
NORTN-TACR Element/Domain
(Simple Type)
Accepts Null Value
SceneForm
Yes, common null values
Field Values
1
2
Yes
No
Additional Information


If the patient arrives by any means other than ground or air EMS (i.e. private vehicle, walk-in, law enforcement,
etc.) then enter the appropriate code for NA
If a patient is transferred into your facility, refer to Page 46 for “Inter-facility Transfer EMS Run Report Present”
Data Source Hierarchy

EMS Run Sheet
References to Other Databases
•
NORTN field only
NORTN 2016 Revision
Page 58
INTER-FACILITY TRANSFER EMS RUN REPORT PRESENT
Data Format is single-choice.
Definition
Inter-facility Transfer EMS Run Report Present documents whether a run report generated during transfer from a
previous hospital to your hospital is found in the patient’s medical record.
NORTN-TACR Data Type
xs- tripform
Multiple Entry Configuration
Required in NORTN-TACR
No
Yes
NORTN-TACR Element/Domain
(Simple Type)
Accepts Null Value
TripForm
Yes, common null values
Field Values
1
2
Yes
No
Additional Information


If the patient has multiple hospital destinations, document only whether the run report is present from the run
in which the transferring agency brings the patient directly to your hospital.
If a patient arrived from the scene of the injury, refer to Page 45 for “Scene EMS Run Report Present”
Data Source Hierarchy

EMS Run Sheet
References to Other Databases

NORTN field only
NORTN 2016 Revision
Page 59
EMS DISPATCH DATE TO SCENE OR TRANSFERRING FACILITY
Data Format is a date.
Definition
The date the unit transporting to your hospital was notified by dispatch.


For inter facility transfer patients, this is the date on which the unit transporting the patient to your facility from
the transferring facility was notified by dispatch or assigned to this transport.
For patients transported from the scene of injury to your hospital, this is the date on which the unit transporting
the patient to your facility from the scene was dispatched.
NORTN-TACR Data Type
xs- date
Multiple Entry Configuration
Required in NORTN-TACR
No
Yes
NORTN-TACR Element/Domain
EMSNotifyDate
(Simple Type)
Accepts Null Value
Yes, common null values
Minimum Constraint 1990 / Maximum Constraint 2030
Field Values

Relevant value for data element
Additional Information


Collected as MMDDYYYY
Used to auto-generate an additional calculated field, Total EMS Time (which is the elapsed time from EMS
dispatch to hospital arrival)
Data Source Hierarchy

EMS Run Sheet
References to Other Databases



NHTSA V.2.2 – E05_04
NTDS 1.2.5
OH-TACR
NORTN 2016 Revision
Page 60
EMS DISPATCH TIME TO SCENE OR TRANSFERRING FACILITY
Data Format is numeric.
Definition
The time the unit transporting to your hospital was notified by dispatch.


For inter facility transfer patients, this is the time at which the unit transporting the patient to your facility from
the transferring facility was notified by dispatch.
For patients transported from the scene of injury to your hospital, this is the time at which the unit transporting
the patient to your facility from the scene was dispatched.
NORTN-TACR Data Type
xs- time
Multiple Entry Configuration
Required in NORTN-TACR
No
Yes
NORTN-TACR Element/Domain
(Simple Type)
Accepts Null Value
EMSNotifyTime
Yes, common null values
Field Values

Relevant value for data element
Additional Information


Document as military time
Used to auto-generate an additional calculated field, Total EMS Time (which is the elapsed time from EMS
dispatch to hospital arrival)
Data Source Hierarchy

EMS Run Sheet
References to Other Databases



NHTSA V.2.2 – E05_04
NTDS 1.2.5
OH-TACR
NORTN 2016 Revision
Page 61
EMS UNIT ARRIVAL DATE AT SCENE OR TRANSFERRING FACILITY
Data Format is date.
Definition
The date the unit transporting to your hospital arrived on the scene/transferring facility (the time the vehicle stopped
moving).


For inter facility transfer patients, this is the date on which the unit transporting the patient to your facility from
the transferring facility arrived at the transferring facility (arrival is defined at date/time when the vehicle
stopped moving).
For patients transported from the scene of injury to your hospital, this is the date on which the unit transporting
the patient to your facility from the scene arrived at the scene (arrival is defined at date/time when the vehicle
stopped moving).
NORTN-TACR Data Type
xs- date
Multiple Entry Configuration
Required in NORTN-TACR
No
Yes
NORTN-TACR Element/Domain
EMSArrivalDate
(Simple Type)
Accepts Null Value
Yes, common null values
Minimum Constraint 1990 / Maximum Constraint 2030
Field Values

Relevant value for data element
Additional Information


Collected as MMDDYYYY
Used to auto-generate an additional calculated fields, Total EMS Response Time (which is the elapsed time from
EMS dispatch to scene arrival) & Total EMS Scene Time (which is the elapsed time from EMS scene arrival to
scene departure)
Data Source Hierarchy

EMS Run Sheet
References to Other Databases



NHTSA V.2.2 – E05_06
NTDS 1.2.5
OH-TACR
NORTN 2016 Revision
Page 62
EMS UNIT ARRIVAL TIME FROM SCENE OR TRANSFERRING FACILITY
Data Format is numeric.
Definition
The time the unit transporting to your hospital arrived on the scene (the time the vehicle stopped moving).


For inter facility transfer patients, this is the time at which the unit transporting the patient to your facility from
the transferring facility arrived at the transferring facility (arrival is defined at date/time when the vehicle
stopped moving).
For patients transported from the scene of injury to your hospital, this is the time at which the unit transporting
the patient to your facility from the scene arrived at the scene (arrival is defined at date/time when the vehicle
stopped moving).
NORTN Data Type
xs- time
Multiple Entry Configuration
Required in TACR
No
Yes
NORTN Element/Domain (Simple
Type)
Accepts Null Value
EMSArrivalTime
Yes, common null values
Field Values

Relevant value for data element
Additional Information


Document as military time
Used to auto-generate an additional calculated fields, Total EMS Response Time (which is the elapsed time from
EMS dispatch to scene arrival) & Total EMS Scene Time (which is the elapsed time from EMS scene arrival to
scene departure)
Data Source Hierarchy

EMS Run Sheet
References to Other Databases



NHTSA V.2.2 – E05_06
NTDS 1.2.5
OH-TACR
NORTN 2016 Revision
Page 63
EMS UNIT DEPARTURE DATE FROM SCENE OR TRANSFERRING FACILITY
Data Format is a date.
Definition
The date the unit transporting to your hospital left the scene (the time the vehicle started moving).


For inter facility transfer patients, this is the date on which the unit transporting the patient to your facility from
the transferring facility departed from the transferring facility (departure is defined at date/time when the
vehicle started moving).
For patients transported from the scene of injury to your hospital, this is the date on which the unit transporting
the patient to your facility from the scene departed from the scene (arrival is defined at date/time when the
vehicle started moving).
NORTN Data Type
xs- date
Multiple Entry Configuration
Required in TACR
No
Yes
NORTN Element/Domain (Simple
EMSLeftDate
Type)
Accepts Null Value
Yes, common null values
Minimum Constraint 1990 / Maximum Constraint 2030
Field Values

Relevant value for data element
Additional Information


Collected as MMDDYYYY
Used to auto-generate an additional calculated field, Total EMS Scene Time (which is the elapsed time from EMS
scene arrival to scene departure)
Data Source Hierarchy

EMS Run Sheet
References to Other Databases



NHTSA V.2.2 – E05_09
NTDS 1.2.5
OH-TACR
NORTN 2016 Revision
Page 64
EMS UNIT DEPARTURE TIME FROM SCENE OR TRANSFERRING FACILITY
Data Format is numeric.
Definition
The time the unit transporting to your hospital left the scene (the time the vehicle started moving).


For inter facility transfer patients, this is the time at which the unit transporting the patient to your facility from
the transferring facility departed from the transferring facility (departure is defined at date/time when the
vehicle started moving).
For patients transported from the scene of injury to your hospital, this is the time at which the unit transporting
the patient to your facility from the scene departed from the scene (arrival is defined at date/time when the
vehicle started moving).
NORTN-TACR Data Type
xs- time
Multiple Entry Configuration
Required in NORTN-TACR
No
Yes
NORTN-TACR Element/Domain
(Simple Type)
Accepts Null Value
EMSLeftTime
Yes, common null values
Field Values

Relevant value for data element
Additional Information


Document as military time
Used to auto-generate an additional calculated field Total EMS Scene Time (which is the elapsed time from EMS
scene arrival to scene departure)
Data Source Hierarchy

EMS Run Sheet
References to Other Databases



NHTSA V.2.2 – E05_09
NTDS 1.2.5
OH-TACR
NORTN 2016 Revision
Page 65
INITIAL FIELD SYSTOLIC BLOOD PRESSURE
Data Format is numeric.
Definition
Initial Field Systolic Blood Pressure is the first recorded systolic blood pressure measured at the scene of injury.
NORTN-TACR Data Type
xs- integer
Multiple Entry Configuration
Required in NORTN-TACR
No
Yes
NORTN-TACR Element/Domain
EMSSbp
(Simple Type)
Accepts Null Value
Yes, common null values
Minimum Constraint 0 / Maximum Constraint 300
Field Values

Relevant value for data element
Additional Information


Used to auto-generate an additional calculated field, Revised Trauma Score---EMS (adult & pediatric)
If patient is transferred to your facility with no EMS run sheet from the scene of injury, record as Not Known/Not
Recorded/Not Documented
Data Source Hierarchy

EMS Run Sheet
References to Other Databases



NHTSA V.2.2 – E14_04
NTDS 1.2.5
OH-TACR
NORTN 2016 Revision
Page 66
INITIAL FIELD PULSE RATE
Data Format is numeric.
Definition
Initial Field Pulse Rate is the first recorded pulse measured at the scene of injury (palpated or auscultated),
expressed as a number per minute.
NORTN-TACR Data Type
xs- integer
Multiple Entry Configuration
Required in NORTN-TACR
No
Yes
NORTN-TACR Element/Domain
EMSPulseRate
(Simple Type)
Accepts Null Value
Yes, common null values
Minimum Constraint 0 / Maximum Constraint 299
Field Values

Relevant value for data element
Additional Information

If patient is transferred to your facility with no EMS run sheet from the scene of injury, record as Not Known/Not
Recorded/Not Documented
Data Source Hierarchy

EMS Run Sheet
References to Other Databases



NHTSA V.2.2 – E14_07
NTDS 1.2.5
OH-TACR
NORTN 2016 Revision
Page 67
INITIAL FIELD RESPIRATORY RATE
Data Format is numeric.
Definition
Initial Field Respiratory Rate is the first recorded respiratory rate measured at the scene of injury (expressed as a
number per minute).
NORTN-TACR Data Type
xs- integer
Multiple Entry Configuration
Required in NORTN-TACR
No
Yes
NORTN-TACR Element/Domain
EMSRespRate
(Simple Type)
Accepts Null Value
Yes, common null values
Minimum Constraint 0 / Maximum Constraint 120
Field Values

Relevant value for data element
Additional Information


Used to auto-generate an additional calculated field, Revised Trauma Score---EMS (adult & pediatric)
If patient is transferred to your facility with no EMS run sheet from the scene of injury, record as Not Known/Not
Recorded/Not Documented
Data Source Hierarchy

EMS Run Sheet
References to Other Databases



NHTSA V.2.2 – E14_11
NTDS 1.2.5
OH-TACR
NORTN 2016 Revision
Page 68
INITIAL FIELD OXYGEN SATURATION
Data Format is numeric.
Definition
Initial Field Oxygen Saturation is the first recorded oxygen saturation measured at the scene of injury (expressed as a
percentage).
NORTN-TACR Data Type
xs- integer
Multiple Entry Configuration
Required in NORTN-TACR
No
Yes
NORTN-TACR Element/Domain
EMSPulseOx
(Simple Type)
Accepts Null Value
Yes, common null values
Minimum Constraint 0 / Maximum Constraint 100
Field Values

Relevant value for data element
Additional Information

If patient is transferred to your facility with no EMS run sheet from the scene of injury, record as Not Known/Not
Recorded/Not Documented
Data Source Hierarchy

EMS Run Sheet
References to Other Databases



NHTSA V.2.2 – E14_09
NTDS 1.2.5
OH-TACR
NORTN 2016 Revision
Page 69
INITIAL FIELD GCS - EYE
Data Format is numeric.
Definition
Initial Field GCS Eye Opening is the first recorded Glasgow Coma Score eye assessment done at the scene of injury.
NORTN-TACR Data Type
xs- integer
Multiple Entry Configuration
Required in NORTN-TACR
No
Yes
NORTN-TACR Element/Domain
EMSGcsEye
(Simple Type)
Accepts Null Value
Yes, common null values
Minimum Constraint 1 / Maximum Constraint 4
Field Values
1
2
3
4
No eye movement when assessed
Opens eyes in response to painful stimulation
Opens eyes in response to verbal stimulation
Opens eyes spontaneously
Additional Information


Used to calculate Overall GCS – EMS Score
If patient is transferred to your facility with no EMS run sheet from the scene of injury, record as Not Known/Not
Recorded/Not Documented

If a patient does not have a numeric GCS score recorded, but written documentation closely (or directly) relates to
verbiage describing a specific level of functioning within the GCS scale, the appropriate numeric score may be
listed. E.g. the chart indicates: "patient withdraws from a painful stimulus," a Motor GCS of 4 may be recorded, IF
there is no other contradicting documentation.
Data Source Hierarchy

EMS Run Sheet
References to Other Databases



NHTSA V.2.2 – E14_15
NTDS 1.2.5
OTR-TACR
NORTN 2016 Revision
Page 70
INITIAL FIELD GCS - VERBAL
Data Format is numeric.
Definition
Initial Field GCS Verbal Response is the first recorded Glasgow Coma Score verbal assessment done at the scene of
injury.
NORTN-TACR Data Type
xs- integer
Multiple Entry Configuration
Required in NORTN-TACR
No
Yes
NORTN-TACR Element/Domain
EMSGcsVerbal
(Simple Type)
Accepts Null Value
Yes, common null values
Minimum Constraint 1 / Maximum Constraint 5
Field Values

Pediatric(<= 2 years of age)
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
Additional Information


Used to calculate Overall GCS – EMS Score
If patient is transferred to your facility with no EMS run sheet from the scene of injury, record as Not Known/Not
Recorded/Not Documented

If a patient does not have a numeric GCS score recorded, but written documentation closely (or directly) relates to
verbiage describing a specific level of functioning within the GCS scale, the appropriate numeric score may be
listed. E.g. the chart indicates: "patient withdraws from a painful stimulus,” a Motor GCS of 4 may be recorded, IF
there is no other contradicting documentation.
Data Source Hierarchy

EMS Run Sheet
References to Other Databases



NHTSA V.2.2 – E14_16
NTDS 1.2.5
OH-TACR
NORTN 2016 Revision
Page 71
INITIAL FIELD GCS - MOTOR
Data Format is numeric.
Definition
Initial Field GCS Motor Response is the first recorded Glasgow Coma Score motor assessment done at the scene of
injury.
NORTN-TACR Data Type
xs- integer
Multiple Entry Configuration
Required in NORTN-TACR
No
Yes
NORTN-TACR Element/Domain
EMSGcsMotor
(Simple Type)
Accepts Null Value
Yes, common null values
Minimum Constraint 1 / Maximum Constraint 6
Field Values

Pediatric (<= 2 years of age)
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
Additional Information



Used to calculate Overall GCS – EMS Score
If patient is transferred to your facility with no EMS run sheet from the scene of injury, record as Not Known/Not
Recorded/Not Documented
If a patient does not have a numeric GCS score recorded, but written documentation closely (or directly) relates
to verbiage describing a specific level of functioning within the GCS scale, the appropriate numeric score may be
listed. E.g. the chart indicates: "patient withdraws from a painful stimulus,” a Motor GCS of 4 may be recorded,
IF there is no other contradicting documentation.
Data Source Hierarchy

EMS Run Sheet
References to Other Databases



NHTSA V.2.2 – E14_17
NTDS 1.2.5
OH-TACR
NORTN 2016 Revision
Page 72
INITIAL FIELD GCS - TOTAL
Data Format is numeric.
Definition
Initial Field Scene GCS Total Score is the first recorded total Glasgow Coma Score done at the scene of injury.
NORTN-TACR Data Type
xs- integer
Multiple Entry Configuration
Required in NORTN-TACR
No
Yes
NORTN-TACR Element/Domain
EMSGcsTotal
(Simple Type)
Accepts Null Value
Yes, common null values
Minimum Constraint 3 / Maximum Constraint 15
Field Values

Relevant value for data element
Additional Information



Used to auto-generate an additional calculated field, Revised Trauma Score---EMS (adult & pediatric)
If the patient is transferred to your facility with no EMS run sheet from the scene of injury, record as Not
Known/Not Recorded/Not Documented
If a patient does not have a numeric GCS recorded, but there is documentation related to their level of
consciousness such as "AAOx3," "awake alert and oriented," or "patient with normal mental status," interpret
this as GCS of 15 IF there is no other contradicting documentation.
Data Source Hierarchy

EMS Run Sheet
References to Other Databases



NHTSA V.2.2 – E14_19
NTDS 1.2.5
OH-TACR
NORTN 2016 Revision
Page 73
INITAIL FIELD GCS QUALIFIER
Data Format is multiple-choice.
Definition
Initial Field GCS Qualifier documents circumstances related to the patient when or near the time that the INITIAL
Field Scene GCS Total Score was obtained.
NORTN-TACR Data Type
xs- integer
Multiple Entry Configuration
Required in NORTN-TACR
Yes, 3
Yes
NORTN-TACR Element/Domain
(Simple Type)
Accepts Null Value
EMSGcsQualifier
Yes, common null values
Field Values
1
2
3
4
Patient is chemically sedated or paralyzed
Obstruction to the patient’s eye(s) prevents accurate eye assessment
Patient is intubated
GCS is valid meaning that the patient is not sedated, not intubated and without eye obstruction
Additional Information


Identifies treatments given to the patient that may affect the first assessment of GCS. This field does not apply
to self-medications the patient may administer (i.e., ETOH, prescriptions, etc.)
Select NA if the patient was not transported to your hospital by EMS
Data Source Hierarchy

EMS Run Sheet
References to Other Databases

OH-TACR
NORTN 2016 Revision
Page 74
SCENE INTERVENTIONS
Data Format is multiple-choice
Definition
Scene Interventions indicates whether a critical procedure was performed by EMS at the scene or enroute to your
hospital, and if so, the procedure that was performed.
NORTN-TACR Data Type
xs- integer
Multiple Entry Configuration
Required in NORTN-TACR
Yes
Yes
NORTN-TACR Element/Domain
(Simple Type)
Accepts Null Value
Yes, common null values
Field Values
1
2
3
4
5
6
CPR
Needle Thoracostomy or Chest Tube
Nasal Endotracheal Tube
Oral Endotracheal Tube
Surgical Airway (i.e. surgical, needle or percutaneous cricothyrotomy, tracheostomy)
Other Non-Surgical Airway (Supraglottic Airway (e.g., Laryngeal Mask Airway [LMA], King, Combitube))
Additional Information

Select NA If the patient was not treated at the scene by EMS
Data Source Hierarchy
1
EMS Run Sheet
References to Other Databases

OH-TACR
NORTN 2016 Revision
Page 75
INTER-FACILITY TRANSFER
Data Format is single-choice.
Definition
Inter-facility Transfer is whether the patient was transferred to your facility from another hospital.
NORTN-TACR Data Type
xs- integer
Multiple Entry Configuration
Required in NORTN-TACR
No
Yes
NORTN-TACR Element/Domain
(Simple Type)
Accepts Null Value
InterFacilityTransfer
Yes, common null values
Field Values
1 Yes
2 No
Additional Information


A patient transferred from a private doctor’s office, stand-alone ambulatory surgery center, and urgent care
clinic or delivered to your hospital by a non-EMS transport is NOT considered an inter-facility transfer.
Outlying facilities (i.e. hospitals and free-standing emergency departments) that provide emergency care
services to assess and/or stabilize a patient are considered to be acute care facilities.
Data Source Hierarchy
1
EMS Run Sheet
References to Other Databases


NTDS 1.2.5
OH-TACR
NORTN 2016 Revision
Page 76
TRANSFERRING HOSPITAL CODE
Data Format is single-choice.
Definition
Transferring Hospital Code documents the Ohio Department of Public Safety (ODPS) assigned-number for the acute
care facility which transferred a trauma patient to your hospital.
NORTN- Data Type
xs- integer
Multiple Entry Configuration
Required in TACR
No
Yes
NORTN- Element/Domain (Simple
Type)
Accepts Null Value
TransferFrom
Yes, common null values
Field Values
•
Four- digit hospital code assigned by the Ohio Department of Public Safety
Data Source Hierarchy
1
2
ED Record
History & Physical Documentation
References to Other Databases

OH-TACR
NORTN 2016 Revision
Page 77
TRAUMA CENTER CRITERIA
Data Format is multiple-choice
Definition
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 Report.
NORTN-TACR Data Type
xs- integer
Multiple Entry Configuration
Required in NORTN-TACR
Yes
Yes
NORTN-TACR Element/Domain
(Simple Type)
Accepts Null Value
TraumaCenter Criteria
Yes, common null values
Field Values
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
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 ventilator support
All penetrating injuries to head, neck, torso, and extremities proximal to elbow or knee
Chest wall instability for 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
Additional Information




“NA” should be used when patient did not arrive by EMS
“NA” should be used if EMS Run Report indicates patient did not meet any Trauma Center Criteria
“Not Known/Not Recorded” should be used if this information is not indicated, as an identical response choice,
on the EMS Run Report or if the EMS Run Report is not available.
Choose all that apply
Data Source Hierarchy
1. EMS Run Sheet
References to Other Databases

NTDS 1.2.5
NORTN 2016 Revision
Page 78
VEHICULAR, PEDESTRIAN, OTHER RISK INJURY
Data Format is multiple-choice
Definition
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 Report.
NORTN-TACR Data Type
xs- integer
Multiple Entry Configuration
Required in NORTN-TACR
Yes
Yes
NORTN-TACR Element/Domain
(Simple Type)
Accepts Null Value
Yes, common null values
Field Values
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
Fall Adults: >20 ft. (on 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
Additional Information




“NA” should be used when patient did not arrive by EMS
“NA” should be used if EMS Run Report indicates patient did not meet any Vehicular, Pedestrian, Other Risk
injury criteria
“Not Known/Not Recorded” should be used if this information is not indicated, as an identical response choice,
on the EMS Run Report or if the EMS Run Report is not available.
Choose all that apply
Data Source Hierarchy
1. EMS Run Sheet
References to Other Databases

NTDS 1.2.5
NORTN 2016 Revision
Page 79
PREHOSPITAL CARDIAC ARREST
Data Format is single-choice.
Definition
Prehospital Cardiac Arrest is whether the patient experienced cardiac arrest prior to ED/Hospital arrival.
NORTN-TACR Data Type
xs- integer
Multiple Entry Configuration
Required in NORTN-TACR
No
Yes
NORTN-TACR Element/Domain
(Simple Type)
Accepts Null Value
PrehospitalArrest
No
Field Values
1. Yes
2. No
Additional Information



A patient who experienced a sudden cessation of cardiac activity. The patient was unresponsive with no normal
breathing and no signs of circulation.
The event must have occurred outside of the reporting hospital, prior to admission at the center in which the
registry is maintained. Prehospital cardiac arrest could occur at a transferring institution.
Any component of basic and/or advanced cardiac life support must have been initiated by a healthcare provider.
Data Source Hierarchy
1.
2.
3.
4.
EMS Run Sheet
Nursing Notes/Flow Sheet
History & Physical
Transfer Notes
References to Other Databases


NTDS 1.2.5
OH-TACR
NORTN 2016 Revision
Page 80
ED/HOSPITAL ARRIVAL DATE
Data Format is a date.
Definition
ED/Hospital Arrival Date is the date that the patient arrived at your ED/hospital.
NORTN-TACR Data Type
xs- date
Multiple Entry Configuration
Required in NORTN-TACR
No
Yes
NORTN-TACR Element/Domain
HospitalArrivalDate
(Simple Type)
Accepts Null Value
Yes, common null values
Minimum Constraint 1990 / Maximum Constraint 2030
Field Values

Relevant value for data entry
Additional Information



If the patient was brought to the ED, enter the date patient arrived at ED
If the patient was directly admitted to the hospital, enter date patient was admitted to the hospital
Collected as MMDDYYYY

Used to auto-generate two additional calculated fields: Total EMS Time: (elapsed time from EMS dispatch to
hospital arrival) and Total Length of Hospital Stay (elapsed time from ED/Hospital Arrival to ED/Hospital
Discharge).
Data Source Hierarchy
1
2
3
4
Triage Form/Trauma Flow Sheet
ED Record
Billing Sheet/Medical Records Coding Summary Sheet
Hospital Discharge Summary
References to Other Databases


NTDS 1.2.5
OH-TACR
NORTN 2016 Revision
Page 81
ED/HOSPITAL ARRIVAL TIME
Data Format is numeric.
Definition
ED/Hospital Arrival Time is the time of day that the patient arrived to your ED/hospital.
NORTN-TACR Data Type
xs- time
Multiple Entry Configuration
Required in NORTN-TACR
No
Yes
NORTN-TACR Element/Domain
(Simple Type)
Accepts Null Value
HospitalArrivalTime
Yes, common null values
Field Values

Relevant value for data entry
Additional Information




If the patient was brought to your hospital ED, enter the time patient arrived at the ED.
If the patient was a directly admit to your hospital and bypassed the ED, enter that time that the patient was
admitted to your hospital.
Document as military time
Used to auto-generate two additional calculated fields: Total EMS Time: (elapsed time from EMS dispatch to
hospital arrival) and Total Length of Hospital Stay (elapsed time from ED/Hospital Arrival to ED/Hospital
Discharge).
Data Source Hierarchy
1
2
3
4
Triage Form/Trauma Flow Sheet
ED Record
Billing Sheet/Medical Records Coding Summary Sheet
Hospital Discharge Summary
References to Other Databases


NTDS 1.2.5
OH-TACR
NORTN 2016 Revision
Page 82
TRAUMA ACTIVATION LEVEL
Data Format is single-choice.
Definition
Trauma Activation Level is the highest level of trauma activation called for the patient when at your hospital.
NORTN-TACR Data Type
xs- integer
Multiple Entry Configuration
Required in NORTN-TACR
No
Yes
NORTN-TACR Element/Domain
(Simple Type)
Accepts Null Value
Alert
Yes, common null values
Field Values
1 Highest Level of Activation
2 Other Level of Activation
3 No Trauma Alert Activation
Additional Information

Select # 3 if your facility does not have a trauma service
Data Source Hierarchy
1
2
Trauma Flow Sheet
ED Record
References to Other Databases

OH-TACR
NORTN 2016 Revision
Page 83
VITAL SIGNS NUMBER
Data Format is numeric.
Definition
Vital Signs Number is the related numeric identifier for where the vital signs were initially measured.
NORTN-TACR Data Type
xs- integer
Multiple Entry Configuration
Required in NORTN-TACR
Yes
Yes
NORTN-TACR Element/Domain
(Simple Type)
Accepts Null Value
VitalSignsNumber
No
Field Values
1
2
Scene
ED/ Initial Hospital
Additional Information
Data Source Hierarchy
1
2
3
Triage Form/Trauma Flow Sheet
ED Record
Nursing Unit Vitals (if a direct admission)
References to Other Databases

NORTN field only
NORTN 2016 Revision
Page 84
VITAL SIGNS LOCATION
Data Format is numeric.
Definition
Vital Signs Number is the unit or hospital location of where the vital signs were initially measured
NORTN-TACR Data Type
xs- integer
Multiple Entry Configuration
Required in NORTN-TACR
Yes
Yes
NORTN-TACR Element/Domain
(Simple Type)
Accepts Null Value
VitalSignsLocation
No
Field Values
SCENE
ED
FLOOR
Scene
Emergency Department
Nursing Unit (Direct Admits)
Additional Information
Data Source Hierarchy
1
2
3
Triage Form/Trauma Flow Sheet
ED Record
Nursing Unit Vitals (if a direct admission)
References to Other Databases

NORTN field only
NORTN 2016 Revision
Page 85
INITIAL ED/HOSPITAL SYSTOLIC BLOOD PRESSURE
Data Format is numeric.
Definition
ED/Hospital Initial Systolic Blood Pressure is the patient’s first recorded systolic blood pressure within 30 minutes or
less of ED/hospital arrival.
NORTN-TACR Data Type
xs- integer
Multiple Entry Configuration
Required in NORTN-TACR
No
Yes
NORTN-TACR Element/Domain
Sbp
(Simple Type)
Accepts Null Value
Yes, common null values
Minimum Constraint 0 / Maximum Constraint 300
Field Values

Relevant value for data element
Additional Information


Use to auto-generated an additional calculated field, Revised Trauma Score---ED (adult & pediatric)
Please note that first recorded/ hospital vitals do not need to be from the same assessment
Data Source Hierarchy
4
5
6
Triage Form/Trauma Flow Sheet
ED Record
Nursing Unit Vitals (if a direct admission)
References to Other Databases


NTDS 1.2.5
OH-TACR
NORTN 2016 Revision
Page 86
INITIAL ED/HOSPITAL PULSE RATE
Data Format is numeric.
Definition
ED/Hospital Initial Pulse Rate is the patient’s first recorded pulse rate within 30 minutes or less of ED/hospital arrival
(palpated or auscultated), expressed as a number per minute.
NORTN-TACR Data Type
xs- integer
Multiple Entry Configuration
Required in NORTN-TACR
No
Yes
NORTN-TACR Element/Domain
PulseRate
(Simple Type)
Accepts Null Value
Yes, common null values
Minimum Constraint 0 / Maximum Constraint 299
Field Values

Relevant value for data element
Data Source Hierarchy
1
2
3
Triage Form/Trauma Flow Sheet
ED Record
Nursing Unit Vitals (if a direct admission)
References to Other Databases


NTDS 1.2.5
OH-TACR
NORTN 2016 Revision
Page 87
INITIAL ED/HOSPITAL RESPIRATORY RATE
Data Format is numeric.
Definition
ED/Hospital Initial Respiratory Rate is the patient’s first recorded respiratory rate within 30 minutes or less of
ED/hospital arrival.
NORTN-TACR Data Type
xs- integer
Multiple Entry Configuration
Required in NORTN-TACR
No
Yes
NORTN-TACR Element/Domain
RespiratoryRate
(Simple Type)
Accepts Null Value
Yes, common null values
Minimum Constraint 0 / Maximum Constraint 120
Field Values

Relevant value for data element
Additional Information


If available, complete addition field Initial ED/Hospital Respiratory Assistance
Used to auto-generate an additional calculated field Revised Trauma Score---ED (adult & pediatric)
Data Source Hierarchy
1
2
3
Triage Form/Trauma Flow Sheet
ED Record
Nursing Unit Vitals (if a direct admission)
References to Other Databases


NTDS 1.2.5
OH-TACR
NORTN 2016 Revision
Page 88
INITIAL ED/HOSPITAL RESPIRATORY ASSISTANCE
Data Format is single-choice.
Definition
ED/Hospital Initial Respiratory Assistance documents whether the patient was receiving respiratory assistance
within 30 minutes or less of ED/hospital arrival.
NORTN-TACR Data Type
xs- integer
Multiple Entry Configuration
Required in NORTN-TACR
No
Yes
NORTN-TACR Element/Domain
(Simple Type)
Accepts Null Value
RespiratoryAssist
Yes, common null values
Field Values
1 Unassisted Respiratory Rate
2 Assisted Respiratory Rate
Additional Information


Only completed if a value is provided for ED/Hospital Initial Respiratory Rate
Respiratory Assistance is defined as mechanical and/or external support of respiration
Data Source Hierarchy
1
2
3
Triage Form/Trauma Flow Sheet
ED Record
Nursing Unit Vitals (if a direct admission)
References to Other Databases


NTDS 1.2.5
OH-TACR
NORTN 2016 Revision
Page 89
INITIAL ED/HOSPITAL OXYGEN SATURATION
Data Format is numeric.
Definition
ED/Hospital Initial Oxygen Saturation is the patient’s first recorded oxygen saturation within 30 minutes or less of
ED/hospital arrival, expressed as a percentage.
NORTN-TACR Data Type
xs- integer
Multiple Entry Configuration
Required in NORTN-TACR
No
Yes
NORTN-TACR Element/Domain
PulseOx
(Simple Type)
Accepts Null Value
Yes, common null values
Minimum Constraint 0 / Maximum Constraint 100
Field Values

Relevant value for data element
Additional Information

If available, complete additional field ED/Hospital Initial Supplemental Oxygen
Data Source Hierarchy
1
2
3
Triage Form/Trauma Flow Sheet
ED Record
Nursing Unit Vitals (if a direct admission)
References to Other Databases


NTDS 1.2.5
OH-TACR
NORTN 2016 Revision
Page 90
INITIAL ED/HOSPITAL SUPPLEMENTAL OXYGEN
Data Format is single-choice.
Definition
ED/Hospital Supplemental Oxygen Administration during Initial Oxygen Saturation Measurement is whether
supplemental oxygen was provided to the patient during the assessment of ED/Hospital Initial Oxygen Saturation
Level within 30 minutes or less of ED/hospital arrival.
NORTN-TACR Data Type
xs- integer
Multiple Entry Configuration
Required in NORTN-TACR
No
Yes
NORTN-TACR Element/Domain
(Simple Type)
Accepts Null Value
SupplementalOxygen
Yes, common null values
Field Values
1 No Supplemental Oxygen
2 Supplemental Oxygen
Additional Information

Only completed if a value is provided for ED/Hospital Initial Oxygen Saturation
Data Source Hierarchy
1
2
3
Triage Form/Trauma Flow Sheet
ED Record
Nursing Unit Vitals (if a direct admission)
References to Other Databases


NTDS 1.2.5
OH-TACR
NORTN 2016 Revision
Page 91
INITIAL ED/HOSPITAL TEMPERATURE
Data Format is numeric.
Definition
ED/Hospital Initial Temperature is the patient’s first recorded temperature within 30 minutes or less of ED/hospital
arrival, documented in degrees celcius.
NORTN-TACR Data Type
xs-decimal
Multiple Entry Configuration
Required in NORTN-TACR
No
Yes
NORTN-TACR Element/Domain
Temperature
(Simple Type)
Accepts Null Value
Yes, common null values
Minimum Constraint 0 /Maximum Constraint 300
Field Values

Relevant value for data element
Data Source Hierarchy
1
2
3
Triage Form/Trauma Flow Sheet
ED Record
Nursing Unit Vitals (if a direct admission)
References to Other Databases


NTDS 1.2.5
OH-TACR
NORTN 2016 Revision
Page 92
INITIAL ED/HOSPITAL GCS - EYE
Data Format is numeric.
Definition
ED/Hospital Initial GCS Eye Opening is the patient’s first recorded Glasgow Coma Score (GCS) eye assessment
documented within 30 minutes or less of ED/hospital arrival in your ED/hospital.
NORTN-TACR Data Type
xs-integer
Multiple Entry Configuration
Required in NORTN-TACR
No
Yes
NORTN-TACR Element/Domain
GcsEye
(Simple Type)
Accepts Null Value
Yes, common null values
Minimum Constraint 1 /Maximum Constraint 4
Field Values
1
2
3
4
No eye movement when assessed
Opens eyes in response to painful stimulation
Opens eyes in response to verbal stimulation
Opens eyes spontaneously
Additional Information

Necessary to calculate Overall GCS ED Score

If a patient does not have a numeric GCS score recorded, but written documentation closely (or directly) relates to
verbiage describing a specific level of functioning within the GCS scale, the appropriate numeric score may be
listed. E.g. the chart indicates: "patient withdraws from a painful stimulus,” a Motor GCS of 4 may be recorded, IF
there is no other contradicting documentation.
Data Source Hierarchy
1
2
3
Triage Form/Trauma Flow Sheet
ED Record
Nursing Unit Vitals (if a direct admission)
References to Other Databases


NTDS 1.2.5
OH-TACR
NORTN 2016 Revision
Page 93
INITIAL ED/HOSPITAL GCS - VERBAL
Data Format is numeric.
Definition
ED/Hospital Initial GCS Verbal Response is the patient’s first recorded Glasgow Coma Score verbal assessment
documented within 30 minutes or less of ED/hospital arrival.
NORTN-TACR Data Type
xs-integer
Multiple Entry Configuration
Required in NORTN-TACR
No
Yes
NORTN-TACR Element/Domain
GcsVerbal
(Simple Type)
Accepts Null Value
Yes, common null values
Minimum Constraint 1 /Maximum Constraint 5
Field Values

Pediatric(<= 2 years of age)
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
Additional Information

Necessary to calculate Overall GCS ED Score


If patient is intubated then the GCS Verbal score is equal to 1
If a patient does not have a numeric GCS score recorded, but written documentation closely (or directly) relates to
verbiage describing a specific level of functioning within the GCS scale, the appropriate numeric score may be
listed. E.g. the chart indicates: "patient withdraws from a painful stimulus,” a Motor GCS of 4 may be recorded, IF
there is no other contradicting documentation.
Data Source Hierarchy
1
2
3
Triage Form/Trauma Flow Sheet
ED Record
Nursing Unit Vitals (if a direct admission)
References to Other Databases


NTDS 1.2.5
OH-TACR
NORTN 2016 Revision
Page 94
INITIAL ED/HOSPITAL GCS - MOTOR
Data Format is numeric.
Definition
ED/Hospital Initial GCS Motor Response is the patient’s first recorded Glasgow Coma Score motor assessment
documented within 30 minutes or less of ED/hospital arrival.
NORTN-TACR Data Type
xs-integer
Multiple Entry Configuration
Required in NORTN-TACR
No
Yes
NORTN-TACR Element/Domain
GcsMotor
(Simple Type)
Accepts Null Value
Yes, common null values
Minimum Constraint 1 /Maximum Constraint 6
Field Values

Pediatric(<= 2 years of age)
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
Additional Information

Necessary to calculate Overall GCS ED Score

If a patient does not have a numeric GCS score recorded, but written documentation closely (or directly) relates to
verbiage describing a specific level of functioning within the GCS scale, the appropriate numeric score may be
listed. E.g. the chart indicates: "patient withdraws from a painful stimulus,” a Motor GCS of 4 may be recorded, IF
there is no other contradicting documentation.
Data Source Hierarchy
1
2
3
Triage Form/Trauma Flow Sheet
ED Record
Nursing Unit Vitals (if a direct admission)
References to Other Databases


NTDS 1.2.5
OH-TACR
NORTN 2016 Revision
Page 95
INITIAL ED/HOSPITAL GCS - TOTAL
Data Format is numeric.
Definition
ED/Hospital Initial GCS Total Score is the patient’s first recorded Glasgow Coma Score documented within 30
minutes or less of ED/hospital arrival in your ED/hospital.
NORTN-TACR Data Type
xs-integer
Multiple Entry Configuration
Required in NORTN-TACR
No
Yes
NORTN-TACR Element/Domain
GcsTotal
(Simple Type)
Accepts Null Value
Yes, common null values
Minimum Constraint 3 /Maximum Constraint 15
Field Values

Relevant value for data element
Additional Information



Utilize only if total score is available without individual component scores
Used to auto-generate an additional calculated field, Revised Trauma Score---ED (adult & pediatric)
If a patient does not have a numeric GCS recorded, but there is documentation related to their level of
consciousness such as "AAOx3," "awake alert and oriented," or "patient with normal mental status," interpret
this as GCS of 15 IF there is no other contradicting documentation.
Data Source Hierarchy
1
2
3
Triage Form/Trauma Flow Sheet
ED Record
Nursing Unit Record (if a direct admission)
References to Other Databases


NTDS 1.2.5
OH-TACR
NORTN 2016 Revision
Page 96
INITIAL ED/HOSPITAL GCS ASSESSMENT QUALIFIERS
Data Format is multiple-choice.
Definition
ED/Hospital Initial GCS Qualifiers are factors that potentially affected the patient’s first Glasgow Coma Score
assessment within 30 minutes or less of ED/hospital arrival.
NORTN-TACR Data Type
xs-integer
Multiple Entry Configuration
Required in NORTN-TACR
Yes, 3
Yes
NORTN-TACR Element/Domain
(Simple Type)
Accepts Null Value
GcsQualifier
Yes, common null values
Field Values
1
2
3
4
Patient Chemically Sedated
Obstruction to the Patient’s Eye
Patient Intubated
Valid GCS: Patient not sedated, not intubated and without eye obstruction
Additional Information

Identifies treatments given to the patient that may affect the first assessment of GCS. This field does not apply
to self-medications the patient may administer (i.e., ETOH, prescriptions, etc.)

If an intubated patient has recently received an agent that results in neuromuscular blockade such that a motor or
eye response is not possible, then the patient should be considered to have an exam that is not reflective of their
neurologic status and the chemical sedation modifier should be selected.
Neuromuscular blockade is typically induced following the administration of agent like succinylcholine,
mivacurium, rocuronium, (cis) atracurium, vecuronium, or pancuronium. While these are the most common
agents, please review what might be typically used in your center so it can be identified in the medical record.
Each of these agents has a slightly different duration of action, so their effect on the GCS depends on when they
were given. For example, succinylcholine's effects last for only 5-10 minutes.


Data Source Hierarchy
1
2
3
4
Triage Form/Trauma Flow Sheet
ED Record
EMS Run Sheet
Nursing Unit Vitals (if a direct admission)
References to Other Databases


NTDS 1.2.5
OH-TACR
NORTN 2016 Revision
Page 97
HEIGHT
Data Format is numeric.
Definition
Height is simply the patient’s height in centimeters
NORTN-TACR Data Type
xs-integer
Multiple Entry Configuration
Required in NORTN-TACR
No
Yes
NORTN-TACR Element/Domain
(Simple Type)
Accepts Null Value
Height
Yes, common null values
Field Values

Height in centimeters
Data Source Hierarchy
1
2
3
Triage Form/Trauma Flow Sheet
ED Record
Nursing Admission Record
References to Other Databases


NTDS 1.2.5
OH-TACR
NORTN 2016 Revision
Page 98
WEIGHT
Data Format is numeric.
Definition
Weight is simply the patient’s weight in kilograms
NORTN-TACR Data Type
xs-integer
Multiple Entry Configuration
Required in NORTN-TACR
No
Yes
NORTN-TACR Element/Domain
(Simple Type)
Accepts Null Value
Weight
Yes, common null values
Field Values

Weight in kilograms
Data Source Hierarchy
1
2
3
4
Triage Form/Trauma Flow Sheet
ED Record
Nursing Admission Record
References to Other Databases


NTDS 1.2.5
OH-TACR
NORTN 2016 Revision
Page 99
ED DISCHARGE WRITTEN DATE
Definition
ED Discharge Date is the date that the order was written for the patient to be discharged from your ED.
Field Values

Relevant value for data element
Common Null Values

Accepted
Additional Information

If the patient is directly admitted to the hospital, code as NA
Data Source Hierarchy
1
2
3
Hospital Discharge Summary
Billing Sheet/Medical Records Coding Summary Sheet
Physicians’ Progress Notes
References to Other Databases


NTDS 1.2.5
OH-TACR
NORTN 2016 Revision
Page 100
ED DISCHARGE WRITTEN TIME
Definition
ED Discharge Time is the time that the order was written for the patient to be discharged from your ED.
Field Values

Relevant value for data element
Common Null Values

Accepted
Additional Information

If the patient is directly admitted to the hospital, code as NA
Data Source Hierarchy
1
2
3
Hospital Record
Billing Sheet/Medical Records Coding Summary Sheet
Physicians’ Progress Notes
References to Other Databases


NTDS 1.2.5
OH-TACR
NORTN 2016 Revision
Page 101
ED DISCHARGE DATE
Data Format is a date.
Definition
ED Discharge Date is the date that the patient was discharged from your ED.
NORTN-TACR Data Type
xs-date
Multiple Entry Configuration
Required in NORTN-TACR
No
Yes
NORTN-TACR Element/Domain
EdDischargeDate
(Simple Type)
Accepts Null Value
Yes, common null values
Minimum Constraint 1990 /Maximum Constraint 2030
Field Values

Relevant value for data element
Additional Information



Collected as MMDDYYYY
Used to auto-generate additional calculated field, Total ED Time (elapsed time from ED admit to ED discharge)
If the patient is directly admitted to the hospital, code as NA
Data Source Hierarchy
4
5
6
Hospital Discharge Summary
Billing Sheet/Medical Records Coding Summary Sheet
Physicians’ Progress Notes
References to Other Databases


NTDS 1.2.5
OH-TACR
NORTN 2016 Revision
Page 102
ED DISCHARGE TIME
Data Format is numeric.
Definition
ED Discharge Time is the time that the patient was discharged from your ED.
NORTN-TACR Data Type
xs- time
Multiple Entry Configuration
Required in NORTN-TACR
No
Yes
NORTN-TACR Element/Domain
(Simple Type)
Accepts Null Value
EdDischargeTime
Yes, common null values
Field Values

Relevant value for data element
Additional Information



Document as military time
Used to auto-generate additional calculated field, Total ED Time (which is the elapsed time from ED arrival to ED
discharge)
If the patient is directly admitted to the hospital, code as NA
Data Source Hierarchy
4
5
6
Hospital Record
Billing Sheet/Medical Records Coding Summary Sheet
Physicians’ Progress Notes
References to Other Databases


NTDS 1.2.5
OH-TACR
NORTN 2016 Revision
Page 103
ED DISCHARGE DISPOSITION
Data Format is single-choice.
Definition
ED Discharge Disposition is a general location of where the patient goes at the time of discharge from your ED.
NORTN-TACR Data Type
xs-integer
Multiple Entry Configuration
Required in NORTN-TACR
No
Yes
NORTN-TACR Element/Domain
(Simple Type)
Accepts Null Value
EdDischargeDispo
Yes, common null values
Field Values
1
2
3
4
5
6
Floor bed (general admission, non-specialty unit bed)
Observation unit
Telemetry/step-down unit (less acuity than ICU)
Home with services
Died
Other (jail, institutional care, mental health, etc.)
7
8
9
10
11
Operating Room
Intensive Care Unit (ICU)
Home without services
Left against medical advice
Transferred to another hospital
Additional Information



Based upon UB-04 disposition coding
If reported as “Died” complete variable Signs of Life
If the patient is directly admitted to the hospital, code as NA
Data Source Hierarchy
1
2
3
Hospital Discharge Summary
Nursing Progress Notes
Social Worker Notes
References to Other Databases


NTDS 1.2.5
OH-TACR
NORTN 2016 Revision
Page 104
ED TRANSFER TO HOSPITAL
Data Format is single-choice.
Definition
ED Transfer to Hospital is a subsequent hospital destination of the patient upon discharge from your ED.
NORTN-TACR Data Type
xs-integer
Multiple Entry Configuration
Required in NORTN-TACR
No
Yes
NORTN-TACR Element/Domain
(Simple Type)
Accepts Null Value
EdDcDestination
Yes, common null values
Field Values

Four- digit hospital code assigned by the Ohio Department of Public Safety
Data Source Hierarchy
1. ED Record
2. History & Physical Documentation
References to Other Databases

OH-TACR
NORTN 2016 Revision
Page 105
DELAY IN TRANSFER
Data Format is single-choice.
Definition
Delay in Transfer is the reason in which a patient’s length of stay is greater than 4 hours when transferred from the
emergency department to another acute care facility.
NORTN-TACR Data Type
xs-integer
Multiple Entry Configuration
Required in NORTN-TACR
No
Yes
NORTN-TACR Element/Domain
(Simple Type)
Accepts Null Value
DelayinTransfer
Yes, common null values
Field Values
AGENCY
MD
TEST
OTH
Agency Delay
Physician Decision Delay
Diagnostic Testing Delay
Other
Data Source Hierarchy
1. ED Record
2. History & Physical Documentation
3. See definitions in “Glossary of Terms”
References to Other Databases

NORTN
NORTN 2016 Revision
Page 106
REASON FOR TRANSFER
Data Format is single-choice.
Definition
Reason for Transfer is the reason why a patient is being transferred from one acute care facility to another acute
care facility.
NORTN-TACR Data Type
xs-integer
Multiple Entry Configuration
Required in NORTN-TACR
No
Yes
NORTN-TACR Element/Domain
(Simple Type)
Accepts Null Value
ReasonForTransfer
Yes, common null values
Field Values
1
2
Higher Level of Care (need for trauma center and/or specialty service not available)
Patient/Family Request/Insurance
Data Source Hierarchy
1. ED Record
2. History & Physical Documentation
3. Progress Notes
References to Other Databases

NORTN FIELD ONLY
NORTN 2016 Revision
Page 107
COMMENTS
Data Format is free text.
Definition
Comments are a free text of any details that are relevant to the patient’s care and hospital stay that are not entered
anywhere else.
SORTS-TACR Data Type
xs-comments
Multiple Entry Configuration
Required in SORTS-TACR
No
Yes
SORTS-TACR Element/Domain
(Simple Type)
Accepts Null Value
COMMENTS
No
Field Values

Relevant value for data element
Additional Information
Data Source Hierarchy
References to Other Databases

NORTN FIELD ONLY
NORTN 2016 Revision
Page 108
SIGNS OF LIFE
Data Format is single-choice.
Definition
Signs of Life are whether the patient arrived for treatment in the ED/ Hospital with signs of life.
NORTN-TACR Data Type
xs-integer
Multiple Entry Configuration
Required in NORTN-TACR
No
Yes
NORTN-TACR Element/Domain
(Simple Type)
Accepts Null Value
SignsOfLife
Yes, common null values
Field Values
1
2
Arrived with no signs of life
Arrived with signs of life
Additional Information

A patient with no signs of life is defined as having none of the following: organized EKG activity, pupillary
responses, spontaneous respiratory attempts or movement, and unassisted blood pressure. This usually implies
the patient was brought to the ED with CPR in progress.
Data Source Hierarchy
1
2
3
Triage Form/Trauma Flow Sheet
Physician’s Progress Notes
ED Documentation
References to Other Databases


NTDS 1.2.5
OH-TACR
NORTN 2016 Revision
Page 109
ALCOHOL USE INDICATOR
Data Format is single-choice.
Definition
Use of alcohol by patient.
NORTN-TACR Data Type
xs-integer
Multiple Entry Configuration
Required in NORTN-TACR
No
Yes
NORTN-TACR Element/Domain
(Simple Type)
Accepts Null Value
AlcoholUse
Yes, common null values
Field Values
1
2
3
4
No (not tested)
No (confirmed by test)
Yes (confirmed by test [trace levels])
Yes (confirmed by test [beyond legal limit])
Additional Information


Blood alcohol concentration (BAC) may be documented at any facility (or setting) treating this patient event
“Beyond legal limit” is defined as a blood alcohol concentration above the legal limit for the States of Ohio,
Kentucky and Indiana
a. Adult Legal Limit is < 0.08 mcg/dl
b. Pediatric (< 21 years of age) Legal Limit is <0.02 mcg/dl


“Trace levels” is defined as any alcohol level below the legal limit, but not zero.
If alcohol use is suspected, but not confirmed by test, record null value “Not Known/Not Recorded.”
Data Source Hierarchy
1
2
Lab Results
ED Physician Notes
References to Other Databases


NTDS 1.2.5
OH-TACR
NORTN 2016 Revision
Page 110
ALCOHOL LEVEL RANGE
Data Format is single-choice.
Definition
Alcohol Level Range is the level of the patient’s Initial blood alcohol level (BAL) drawn at your hospital when the BAL
is positive.
NORTN-TACR Data Type
xs-integer
Multiple Entry Configuration
Required in NORTN-TACR
No
Yes
NORTN-TACR Element/Domain
AlcoholLevel
(Simple Type)
Accepts Null Value
Yes, common null values
Minimum Constraint 0/ Maximum Constraint 1000
Field Values

Relevant value for data element
Additional Information




This field is answered only if the patient is positive for alcohol use.
Document the patients BAL in whole numbers. Example: 102.
Document NA if patient did not have a blood alcohol level tested.
Examples:
i. 0.104 > 104.0, which converts to “104”. Move the decimal 3 places to the right. The zero gets
dropped.
ii. 0.354 > 354.0 > 354. Again, move the decimal 3 places to the right. The zero gets dropped.
iii. 180 > 180.0 > 0.18. The decimal is moved 3 places to the left, when you convert a whole
number reading to a decimal reading.
Data Source Hierarchy
1
2
Lab Results
ED Physician Notes
References to Other Databases

OH-TACR
NORTN 2016 Revision
Page 111
DRUG USE INDICATOR
Data Format is single-choice.
Definition
Use of drugs by patient.
NORTN-TACR Data Type
xs-integer
Multiple Entry Configuration
Required in NORTN-TACR
No
Yes
NORTN-TACR Element/Domain
(Simple Type)
Accepts Null Value
DrugUse
Yes, common null values
Field Values
1
2
3
4
No (not tested)
No (confirmed by test)
Yes (confirmed by test [prescription drug])
Yes (confirmed by test [illegal use drug])
Additional Information




Drug use may be documented at any facility (or setting) treating this patient event.
“Illegal use drug” includes illegal use of prescription drugs.
If drug use is suspected, but not confirmed by test, record null value “Not Known/Not Recorded.”
This data element refers to drug use by the patient and does not include medical treatment.
Data Source Hierarchy
1
2
Lab Results
ED Physician Notes
References to Other Databases


NTDS 1.2.5
OH-TACR
NORTN 2016 Revision
Page 112
ADMITTING SPECIALTY
Data Format is single-choice.
Definition
Admitting Specialty is the medical specialty of the attending physician who admits the patient to your hospital.
NORTN-TACR Data Type
xs-string
Multiple Entry Configuration
Required in NORTN-TACR
No
Yes
NORTN-TACR Element/Domain
(Simple Type)
Accepts Null Value
AdmSvc
Yes, common null values
Field Values
0
1
2
3
4
5
6
7
8
9
Not Admitted (Died in your ED, transferred to another facility or discharged home)
General Surgery (Includes adult general and adult trauma surgery)
Neurosurgery
Orthopedic Surgery
Pediatric Surgery (Includes pediatric general surgery)
Burn Service
Thoracic Surgery
Plastic Surgery
All Other Surgical Services
Non-Surgical Service(s)
Additional Information

This is not necessarily the service to which the patient is designated upon admission to the hospital, but the
medical specialty of the patient’s attending physician
Data Source Hierarchy
1
2
3
4
ED Record
Trauma Flow Sheet
Billing/Registration Sheet
History & Physical
References to Other Databases

NORTN field only
NORTN 2016 Revision
Page 113
HOSPITAL PROCEDURE CODE
Data Format is multiple-choice.
Definition
Hospital Procedure Code is all operative or essential procedures conducted on the patient during his/her stay at your
hospital.
NORTN-TACR Data Type
xs-string
Multiple Entry Configuration
Required in NORTN-TACR
Yes, 200
Yes
NORTN-TACR Element/Domain
(Simple Type)
Accepts Null Value
HospitalProcedureCode
Yes, common null values
Field Values

All values for data element
At minimum:
Code
Description
AGRAM
Arteriograms
BBOARD
Backboard
PRBC
Packed Red Blood Cells
FFP
Fresh Frozen Plasma
CELL
Cell Saver
CRYO
Cryoprecipitate
MASS
Mass Transfusion
PLAT
Platelets
CCOLLAR
Cervical Collar
CENTLINE
Central Line
CHEST
Chest Tube insertion/Thoracotomy
CLRD
Closed reduction of dislocation
CPR
CPR
CT
Other CT Scan
CTABD
CT Scan Abdomen
CTCHEST
CT Scan Chest
CTFACE
CT Scan Face
CTHEAD
CT Scan Head
CTSPINE
CT scan Spine
DPL
Diagnostic Preitoneal Lavage
FAST
FAST Exam
INTUB
Intubation
MRIBRAIN
MRI Brain
NONE
None
OR
Operative Procedure
OR.ORTHO
Ortho operative procedure
OTHER
Other unspecified procedure
SUTURE
Suture of Skin
NORTN 2016 Revision
Page 114
THORA
TRACH
VENT
Needle Thoracentesis
Tracheostomy
Mechanical Ventilation < 96 Hours or ≥ 96 Hours
Additional Information



Operative and/or essential procedures are defined as procedures performed in the Operating Room, Emergency
Department, and/or Intensive Care Unit that were essential to the diagnoses, stabilization, or treatment of the
patient’s specific injuries or their complications at your hospital.
Include only procedures performed at your hospital.
At a minimum, the procedures listed on the following page should be captured for NORTN-TACR. The hospital
may choose to capture additional procedures for internal use. Procedures included on in the Procedures List
that are designated with an asterisk have the potential to be performed multiple times during one episode of
hospitalization. In this case, capture only the first event. If there is no asterisk, capture each event even if there
is more than one.
Data Source Hierarchy
1
2
3
4
5
6
Operative Reports
ED and ICU Records
Trauma Flow Sheet
Anesthesia Record
Billing Sheet/Medical Records Coding Summary Sheet
Hospital Discharge Summary
References to Other Databases

NORTN field only
NORTN 2016 Revision
Page 115
SUGGESTED PROCEDURE LIST FOR HOSPITAL PROCEDURES DATA
FIELD
DIAGNOSTIC & THERAPEUTIC IMAGING
Computed tomographic studies*
Diagnostic ultrasound (includes FAST)
Doppler ultrasound of extremities*
Angiography
Angioembolization
Echocardiography
Cystogram
Inferior vena cava (IVC) filter
Urethrogram
CARDIOVASCULAR
Central venous catheterization*
Pulmonary artery catheterization*
Cardiac output monitoring*
Open cardiac massage
Cardiopulmonary Resuscitation (CPR)
CENTRAL NERVOUS SYSTEM
Insertion of ICP monitor
Ventriculostomy
Cerebral oxygen monitoring
GASTROINTESTINAL
Endoscopy (includes gastroscopy, sigmoidoscopy,
colonoscopy)
Gastrostomy/jejunostomy/gastrojejunostomy
(percutaneous/or endoscopic)
GENITOURINARY
Ureteric catheterization (i.e. ureteric stent)
Suprapubic cystostomy
MUSCULOSKELETAL
Soft tissue/bony debridement*
Closed reduction fractures
Skeletal (and halo) traction*
Fasciotomy
RESPIRATORY
Insertion of endotracheal tube*
Continuous invasive mechanical ventilation
Chest tube*
Bronchoscopy
Tracheostomy
TRANSFUSION
The following blood products should be captured over
first 24 hours after hospital arrival:
Transfusion of red cells *
Transfusion of platelets *
Transfusion of plasma *
In addition to coding the individual blood products
listed above assign the 99.01 ICD-9 procedure code on
patients that receive > 10 units of blood products over
first 24 hours following hospital arrival *
OTHER
Hyperbaric oxygen
Decompression chamber
Total Parenteral Nutrition (TPN)
*May be performed multiple times
during hospitalization
NORTN 2016 Revision
Page 116
PROCEDURE EPISODE
Data Format is multiple-choice.
Definition
Procedure Episode documents the order of the surgical procedures performed within the operative suite while the
patient was in your hospital.
NORTN-TACR Data Type
xs-string
Multiple Entry Configuration
Required in NORTN-TACR
Yes, 200
Yes
NORTN-TACR Element/Domain
(Simple Type)
Accepts Null Value
ProcedureEpisode
Yes, common null values
Field Values
1
2
3
4
5
6
7
8
9
10
First Operative Episode
Second Operative Episode
Third Operative Episode
Fourth Operative Episode
Fifth Operative Episode
Sixth Operative Episode
Seventh Operative Episode
Eighth Operative Episode
Ninth Operative Episode
Tenth or More Operative Episode
Additional Information



Include only those operative procedures performed at your hospital
This field is linked to the Hospital Procedures Field
Leave field blank if procedure was not performed in the Operating Room
Data Source Hierarchy
1
Operative Reports
References to Other Databases


NTDS 1.2.5
OH-TACR
NORTN 2016 Revision
Page 117
PROCEDURE LOCATION
Data Format is multiple-choice.
Definition
Procedure Location documents the location of the procedures performed while the patient was in your hospital.
NORTN-TACR Data Type
xs-string
Multiple Entry Configuration
Required in NORTN-TACR
Yes, 200
Yes
NORTN-TACR Element/Domain
(Simple Type)
Accepts Null Value
ProcedureLocation
Yes, common null values
Field Values
1
2
3
4
5
6
Emergency Department
Operating Room
ICU
Floor
Radiology
Other Specialty Area
Additional Information



Include only those operative procedures performed at your hospital
This field is linked to the Hospital Procedures Field
Other Specialty Area includes: Endo, angio, cardiac cath lab, dialysis, ect.
Data Source Hierarchy
1
Operative Reports
References to Other Databases

NORTN field only
NORTN 2016 Revision
Page 118
HOSPITAL PROCEDURES ICD-10
Data Format is multiple-choice.
Definition
Hospital Procedures ICD-10 is all operative or essential procedures conducted on the patient during his/her stay at
your hospital with the designated ICD-10-PCS code.
NORTN-TACR Data Type
xs-string
Multiple Entry Configuration
Required in NORTN-TACR
Yes, 200
Yes
NORTN-TACR Element/Domain
(Simple Type)
Accepts Null Value
HospitalProcedureICD-9
Yes, common null values
Field Values


Major and minor procedure (ICD-10-CM) inpatient codes
The maximum number of procedures that may be reported for a patient is 200
Additional Information



Operative and/or essential procedures are defined as procedures performed in the Operating Room, Emergency
Department, and/or Intensive Care Unit that were essential to the diagnoses, stabilization, or treatment of the
patient’s specific injuries or their complications at your hospital.
Include only procedures performed at your hospital.
At a minimum, the procedures listed on the following page should be captured for NORTN-TACR. The hospital
may choose to capture additional procedures for internal use. Procedures included on in the Procedures List
that are designated with an asterisk have the potential to be performed multiple times during one episode of
hospitalization. In this case, capture only the first event. If there is no asterisk, capture each event even if there
is more than one.
Data Source Hierarchy
1
2
3
4
5
6
Operative Reports
ED and ICU Records
Trauma Flow Sheet
Anesthesia Record
Billing Sheet/Medical Records Coding Summary Sheet
Hospital Discharge Summary
References to Other Databases


NTDS 1.2.5
OH-TACR
NORTN 2016 Revision
Page 119
HOSPITAL PROCEDURE START DATE
Data Format is a date.
Definition
The date operative and essential procedures were performed.
NORTN-TACR Data Type
xs- date
Multiple Entry Configuration
Required in NORTN-TACR
Yes, 200
Yes
NORTN-TACR Element/Domain
(Simple Type)
Accepts Null Value
HospProcedureDate
Yes, common null values
Field Values

Relevant value for data element
Additional Information


Collected as MMDDYYYY
This field is linked to the Hospital Procedures Field
Data Source Hierarchy
1
2
3
4
5
Operative Reports
Anesthesia Record
OR Nurses’ Notes
Emergency Department Record
EMS Run Report
References to Other Databases


NTDS 1.2.5
OH-TACR
NORTN 2016 Revision
Page 120
HOSPITAL PROCEDURE START TIME
Data Format is numeric.
Definition
The time operative and essential procedures were performed.
NORTN-TACR Data Type
xs- time
Multiple Entry Configuration
Required in NORTN-TACR
Yes, 200
Yes
NORTN-TACR Element/Domain
(Simple Type)
Accepts Null Value
HospProcedureTime
Yes, common null values
Field Values

Relevant value for data element
Additional Information



Document as military time
Procedure start time is defined as the time that the incision was made or that the essential procedure started
This field is linked to the Hospital Procedures Field
Data Source Hierarchy
1
2
3
4
5
Operative Reports
Anesthesia Record
OR Nurses’ Notes
Emergency Department Record
EMS Run Report
References to Other Databases


NTDS 1.2.5
OH-TACR
NORTN 2016 Revision
Page 121
CO-MORBID CONDITIONS
Data Format is multiple-choice.
Definition
Co-morbid Conditions are pre-existing health factors present in the patient prior to arrival at your ED/hospital.
NORTN-TACR Data Type
xs- integer
Multiple Entry Configuration
Required in NORTN-TACR
Yes, 23
Yes
NORTN-TACR Element/Domain
(Simple Type)
Accepts Null Value
Comorbid
Yes, common null values
Field Values
0
1
2
3
4
5
6
7
8
9
10
11
No Known Co-morbid Conditions
Other Co-morbid Conditions Not Otherwise Listed Here
Alcohol Use Disorder
Ascites within 30 days (Retired 2016)
Bleeding Disorder
Currently receiving Chemotherapy for Cancer
Congenital Anomalies
Congestive Heart Failure
Current Smoker
Chronic Renal Failure
Cerebrovascular Accident (CVA)
Diabetes Mellitus
12
13
15
16
Disseminated Cancer
Advanced Directive Limiting Care
Functionally Dependent Health Status
History of Angina Within Past 1 Month
17 History of Myocardial Infarction
18 History of PVD
19 Hypertension Requiring Medication
21 Prematurity
22 Obesity (Retired 2016)
23 Chronic Obstructive Pulmonary Disease (COPD)
24 Steroid Use
25 Cirrhosis
26 Dementia
27 Major Psychiatric Illness
28 Drug Use Disorder
29 Pre- Hospital Cardiac Arrest with CPR (Retired 2016)
30 Attention Deficit Disorder/ attention deficit hyperactivity
disorder (ADD/ADHD)
50 Osteoporosis
51 Hearing Impaired
52 Vision Impairment
53 Language Barrier
Additional Information




Field Value #0, No Known Co-morbid Conditions is used for patients with no known co-morbid conditions as coded by the hospitals or
defined within the NTDS Data Dictionary.
Field value #1, Other Co-morbid Conditions Not Otherwise Listed Here, is used if that patient has a pre-existing condition that is not
included in this list.
Field value #13, Advanced Directive Limiting Care, is selected here ONLY if the patient had a Do Not Resuscitate (DNR) PRIOR TO the
patient’s arrival in your ED/hospital. To document patient DNR orders issued AFTER arrival to your ED/hospital, see next page.
See Appendix A – Comorbid Conditions for field value definitions
Data Source Hierarchy
1
2
3
History and Physical
Discharge Sheet
Billing Sheet
References to Other Databases


NTDS 1.2.5
OH-TACR
NORTN 2016 Revision
Page 122
DNR STATUS
Data Format is single-choice.
Definition
DNR Status documents the presence of a physician’s order to withhold select resuscitative efforts from the patient,
and whether the order was issued prior to or during the patient’s stay at your ED/hospital.
NORTN-TACR Data Type
xs-string
Multiple Entry Configuration
Required in NORTN-TACR
No
Yes
NORTN-TACR Element/Domain
(Simple Type)
Accepts Null Value
DNR
Yes, common null values
Field Values
0
1
2
Not a DNR patient (patient is to receive all resuscitative efforts if needed)
DNR status ordered prior to patient’s arrival at your hospital
DNR status ordered after patient’s arrival to your hospital
Additional Information




This field is completed for each patient
DNR status is typically ordered for a patient who does not wish to be resuscitated in the event of a cardiac arrest
(no palpable pulse) or respiratory arrest (no spontaneous respirations or the presence of labored breathing)
near the end of life.
A DNR status includes both DNR-CC (comfort care) and DNR-CCA (comfort care arrest) orders.
DNR may also be referred to as Allow Natural Death (AND)
Data Source Hierarchy
1
2
3
4
Do Not Resuscitate Document
History and Physical
Discharge Sheet
Billing Sheet
References to Other Databases


NTDS 1.2.5
OH-TACR
NORTN 2016 Revision
Page 123
INJURY DIAGNOSES ICD-10
Data Format is multiple-choice.
Definition
Injury Diagnoses are the patient’s diagnoses for all injuries identified at your ED/hospital for this injury event.
Diagnoses must be confirmed by a physician at your facility.
NORTN-TACR Data Type
xs-string
Multiple Entry Configuration
Required in NORTN-TACR
Yes, 50
Yes
NORTN-TACR Element/Domain
(Simple Type)
Accepts Null Value
InjuryDiagnoses
Yes, common null values
Field Values

Injury diagnoses are defined by ICD-10-CM codes; refer to inclusion criteria
Additional Information


Can be utilized to generate Abbreviated Injury Score and Injury Severity Score
The maximum number of diagnoses that may be reported for an individual patient is 50
Data Source Hierarchy
1
2
3
4
5
6
7
Autopsy Report
Operative Report
Discharge Summary
Trauma Flow Sheet
Radiology Results
Billing Sheet/Medical Records Coding Summary Sheet
ED and ICU Records
References to Other Databases


NTDS 1.2.5
OH-TACR
NORTN 2016 Revision
Page 124
INJURY DIAGNOSES DESCRIPTION
Data Format is multiple-choice (Free Text).
Definition
Injury Diagnoses Description is the patient’s description for all injuries identified at your ED/hospital for this injury
event that match the corresponding ICD-9 assigned. Diagnoses must be confirmed by a physician at your facility.
NORTN-TACR Data Type
xs-string
Multiple Entry Configuration
Required in NORTN-TACR
Yes, 50
Yes
NORTN-TACR Element/Domain
(Simple Type)
Accepts Null Value
InjuryDiagnosesDescript
Yes, common null values
Field Values

Relevant Value for Data Element
Additional Information



Provide detailed information of injury
o Example: Right femur fx, comminuted and displaced
o Scalp laceration, 7 cm
Can be utilized to generate Abbreviated Injury Score and Injury Severity Score
The maximum number of diagnoses that may be reported for an individual patient is 50
Data Source Hierarchy
1
2
3
4
5
6
7
Autopsy Report
Operative Report
Discharge Summary
Trauma Flow Sheet
Radiology Results
Billing Sheet/Medical Records Coding Summary Sheet
ED and ICU Records
References to Other Databases

NORTN field only
NORTN 2016 Revision
Page 125
ISS BODY REGION
Data Format is multiple-choice.
Definition
The Injury Severity Score (ISS) body region codes that reflect the patient’s injuries.
NORTN-TACR Data Type
xs-integer
Multiple Entry Configuration
Required in NORTN-TACR
Yes, 50
Yes
NORTN-TACR Element/Domain
IssRegion
(Simple Type)
Accepts Null Value
Yes, common null values
Minimum Constraint 1/Maximum Constraint 6
Field Values
1
2
3
4
5
6
Head or Neck
Face
Chest
Abdominal or Pelvic Contents
Extremities or Pelvic Girdle
External
Additional Information






Field value #1, Head or Neck, includes injury to the brain, skull, cervical spine and/or cervical spine fractures
Field value #2, Face, includes those areas involving the mouth, ears, nose and/or facial bones
Field value #3, Chest, includes all lesions to internal organs within the chest, diaphragm, rib cage and/or thoracic spine
Field value #4, Abdominal or Pelvic Contents, includes all lesions to internal organs within the abdomen and lumbar spine
Field value #5, Extremities or Pelvic Girdle, includes sprains, dislocations, fractures and amputations except for the spinal
column, skull and rib cage
Field value #6, External, includes injuries such as lacerations, contusions, abrasions and burns independent of their location
on the body surface
Data Source Hierarchy
1
2
3
4
5
6
7
Autopsy Report
Operative Report
Discharge Summary
Trauma Flow Sheet
Radiology Results
Billing Sheet/Medical Records Coding Summary Sheet
ED and ICU Records
References to Other Databases


NTDS 1.2.5
OH-TACR
NORTN 2016 Revision
Page 126
AIS PRE-DOT CODE
Data Format is multiple-choice.
Definition
AIS Pre-dot Code is a component of the Abbreviated Injury Scale (AIS) code that reflects the patient’s injuries
diagnosed at your ED/hospital.
NORTN-TACR Data Type
xs-string
Multiple Entry Configuration
Required in NORTN-TACR
Yes, 50
Yes
NORTN-TACR Element/Domain
(Simple Type)
Accepts Null Value
AisPre-dot
Yes, common null values
Field Values

The pre-dot code is the 6 digits preceding the decimal point in an associated AIS code
Additional Information

Can be utilized to generate Abbreviated Injury Score and Injury Severity Score
Data Source Hierarchy

AIS Dictionary
References to Other Databases


NTDS 1.2.5
OH-TACR
NORTN 2016 Revision
Page 127
AIS SEVERITY
Data Format is multiple-choice.
Definition
AIS Severity is the Abbreviated Injury Scale (AIS) severity codes that reflect the patient’s injuries diagnosed at your
ED/hospital.
NORTN-TACR Data Type
xs-integer
Multiple Entry Configuration
Required in NORTN-TACR
Yes, 50
Yes
NORTN-TACR Element/Domain
AisSeverity
(Simple Type)
Accepts Null Value
Yes, common null values
Minimum Constraint 1 /Maximum Constraint 9
Field Values
1
2
3
4
5
6
7
Minor Injury
Moderate Injury
Serious Injury
Severe Injury
Critical Injury
Maximum Injury, Virtually Non-survivable
Not Possible to Assign an AIS
Additional Information

Field value #7, Not Possible to Assign an AIS, is chosen if the severity of an injury is not known
Data Source Hierarchy

AIS Dictionary using ICD-9-CM injury codes found
References to Other Databases


NTDS 1.2.5
OH-TACR
NORTN 2016 Revision
Page 128
AIS VERSION
Data Format is single-choice.
Definition
AIS version is the software version used to calculate Abbreviated Injury Scale (AIS) severity codes for the patient’s
current injury event.
NORTN-TACR Data Type
xs- integer
Multiple Entry Configuration
Required in NORTN-TACR
No
Yes
NORTN-TACR Element/Domain
(Simple Type)
Accepts Null Value
AisVersion
Yes, common null values
Field Values
1
AIS 05
Data Source Hierarchy

AIS Dictionary
References to Other Databases


NTDS 1.2.5
OH-TACR
NORTN 2016 Revision
Page 129
INJURY SEVERITY SCORE
Data Format is single-choice.
Definition
Injury Severity Score (ISS) is a nationally-accepted scoring system that reflects the patient’s injuries for this injury
event.
NORTN-TACR Data Type
Multiple Entry Configuration
Required in NORTN-TACR
xsinteger
No
Yes
NORTN-TACR Element/Domain (Simple
Iss
Type)
Accepts Null Value
Yes, common null values
Minimum Constraint 1 / Maximum Constraint 75
Field Values

Relevant ISS value for the constellation of injuries
Data Source Hierarchy

AIS Dictionary
References to Other Databases


NTDS 1.2.5
OH-TACR
NORTN 2016 Revision
Page 130
TOTAL ICU LENGTH OF STAY
Data Format is numeric.
Definition
Total ICU Length of Stay documents the total number of days that the patient spent in any intensive care unit (ICU)
(including all episodes) while in your hospital.
NORTN-TACR Data Type
xs- integer
Multiple Entry Configuration
Required in NORTN-TACR
No
Yes
NORTN-TACR Element/Domain
TotalIcuLos
(Simple Type)
Accepts Null Value
Yes, common null values
Minimum Constraint 0 /Maximum Constraint 400
Field Values

Relevant numeric value
Additional Information






Recorded in full day increments with any partial calendar day counted as a full calendar day.
The calculation assumes that the date and time of starting and stopping an ICU episode are recorded in the
patient’s chart.
If any dates are missing then a LOS cannot be calculated.
If patient has multiple ICU episodes on the same calendar day, count that day as one calendar day.
At no time should the ICU LOS exceed the Hospital LOS.
If the patient had no ICU days according to the above definition, code as ‘Not applicable.’
Example #
A.
B.
Start Date
01/01/11
01/01/11
01/01/11
Start Time
01:00
01:00
16:00
Stop Date
01/01/11
01/01/11
01/01/11
Stop Time
04:00
04:00
18:00
01/01/11
01/02/11
01:00
16:00
01/01/11
01/02/11
04:00
18:00
01/01/11
01/02/11
01:00
09:00
01/01/11
01/02/11
16:00
18:00
01/01/11
01/02/11
01:00
09:00
01/01/11
01/02/11
16:00
21:00
F.
G.
01/01/11
01/01/11
Unknown
Unknown
01/01/11
01/02/11
16:00
16:00
H.
01/01/11
01/02/11
Unknown
18:00
01/02/11
01/02/11
16:00
Unknown
01/01/11
01/02/11
Unknown
18:00
01/02/11
01/02/11
16:00
20:00
01/01/11
Unknown
01/02/11
16:00
C.
D.
E.
I.
J.
LOS
1 day (one calendar day)
1 day (2 episodes within one calendar
day)
2 days (episodes on 2 separate
calendar days)
2 days (episodes on 2 separate
calendar days)
2 days (episodes on 2 separate
calendar days)
1 day
2 days (patient was in ICU on 2
separate calendar days)
2 days (patient was in ICU on 2
separate calendar days)
2 days (patient was in ICU on 2
separate calendar days)
NORTN 2016 Revision
Page 131
K.
01/03/11
18:00
01/03/11
20:00
Unknown
01/03/11
Unknown
18:00
01/02/11
01/03/11
16:00
20:00
3 days (patient was in ICU on 3
separate calendar days)
Unknown (can’t compute total)
Data Source Hierarchy
1
2
3
ICU Nursing Flow Sheet
Calculate Based on Admission Form and Discharge Sheet
Nursing Progress Notes
References to Other Databases


NTDS 1.2.5
OH-TACR
NORTN 2016 Revision
Page 132
TOTAL VENTILATOR DAYS
Data Format is numeric.
Definition
Total Ventilator Days documents the total number of days that the patient spent on mechanical ventilation
(excluding time in the OR) while in your hospital.
NORTN-TACR Data Type
xs- integer
Multiple Entry Configuration
Required in NORTN-TACR
No
Yes
NORTN-TACR Element/Domain
TotalVentDays
(Simple Type)
Accepts Null Value
Yes, common null values
Minimum Constraint 0 /Maximum Constraint 400
Field Values

Relevant value for data element
Additional Information







Excludes mechanical ventilation time associated with OR procedures.
Non-invasive means of ventilatory support (CPAP or BIPAP) should not be considered in the calculation of
ventilator days.
Recorded in full day increments with any partial calendar day counted as a full calendar day.
The calculation assumes that the date and time of starting and stopping Ventilator episode are recorded in the
patient’s chart.
If any dates are missing then a Total Vent Days cannot be calculated.
At no time should the Total Vent Days exceed the Hospital LOS.
If the patient was not on the ventilator according to the above definition, code as ‘Not applicable.’
Example #
Start Date
Start Time
Stop Time
LOS
01:00
01:00
16:00
Stop
Date
01/01/11
01/01/11
01/01/11
A.
B.
01/01/11
01/01/11
01/01/11
04:00
04:00
18:00
1 day (one calendar day)
01/01/11
01/02/11
01:00
16:00
01/01/11
01/02/11
04:00
18:00
01/01/11
01/02/11
01:00
09:00
01/01/11
01/02/11
16:00
18:00
01/01/11
01/02/11
01:00
09:00
01/01/11
01/02/11
16:00
21:00
F.
G.
01/01/11
01/01/11
Unknown
Unknown
01/01/11
01/02/11
16:00
16:00
H.
01/01/11
Unknown
01/02/11
16:00
C.
D.
E.
1 day (2 episodes within
one calendar day)
2 days (episodes on 2
separate calendar days)
2 days (episodes on 2
separate calendar days)
2 days (episodes on 2
separate calendar days)
1 day
2 days (patient was on Vent
on 2 separate calendar
days)
NORTN 2016 Revision
Page 133
Example #
I.
J.
K.
Start Date
Start Time
Stop Time
LOS
18:00
Stop
Date
01/02/11
01/02/11
Unknown
2 days (patient was on Vent
on 2 separate calendar
days)
01/01/11
01/02/11
Unknown
18:00
01/02/11
01/02/11
16:00
20:00
01/01/11
01/03/11
Unknown
18:00
01/02/11
01/03/11
16:00
20:00
Unknown
01/03/11
Unknown
18:00
01/02/11
01/03/11
16:00
20:00
2 days (patient was in on
Vent on 2 separate
calendar days)
3 days (patient was on Vent
on 3 separate calendar
days)
Unknown (can’t compute
total)
Data Source Hierarchy
1
2
3
4
ICU Respiratory Therapy Flowsheet
ICU Nursing Flow Sheet
Physician’s Daily Progress Notes
Calculate Based on Admission Form and Discharge Sheet
References to Other Databases


NTDS 1.2.5
OH-TACR
NORTN 2016 Revision
Page 134
HOSPITAL DISCHARGE ORDER WRITTEN DATE
Definition
Hospital Discharge Date is the date that the order was written for the patient to be discharged from your hospital.
Field Values

Relevant value for data element
Common Null Values

Accepted
Data Source Hierarchy
1
2
3
Hospital Record
Billing Sheet/Medical Records Coding Summary Sheet
Physician Discharge Summary
References to Other Databases


NTDS 1.2.5
OH-TACR
NORTN 2016 Revision
Page 135
HOSPITAL DISCHARGE ORDER WRITTEN TIME
Definition
Hospital Discharge Time is the time of day that the order was written for the patient to be discharged from your
hospital.
Field Values

Relevant value for data element
Common Null Values

Accepted
Data Source Hierarchy
1
2
3
Hospital Record
Billing Sheet/Medical Records Coding Summary Sheet
Physician Discharge Summary
References to Other Databases


NTDS 1.2.5
OH-TACR
NORTN 2016 Revision
Page 136
HOSPITAL DISCHARGE DATE
Data Format is a date.
Definition
Hospital Discharge Date is simply the date that the patient was discharged from your hospital.
NORTN-TACR Data Type
xs-date
Multiple Entry Configuration
Required in NORTN-TACR
No
Yes
NORTN-TACR Element/Domain
HospitalDcDate
(Simple Type)
Accepts Null Value
Yes, common null values
Minimum Constraint 1990 /Maximum Constraint 2030
Field Values

Relevant value for data element
Additional Information


Collected as MMDDYYYY
Used to calculate Total Length of Hospital Stay (which is the elapsed time from ED/Hospital arrival to Hospital
Discharge)
Data Source Hierarchy
4
5
6
Hospital Record
Billing Sheet/Medical Records Coding Summary Sheet
Physician Discharge Summary
References to Other Databases


NTDS 1.2.5
OH-TACR
NORTN 2016 Revision
Page 137
HOSPITAL DISCHARGE TIME
Data Format is numeric.
Definition
Hospital Discharge Time is simply the time of day that the patient was discharged from your hospital.
NORTN-TACR Data Type
xs-time
Multiple Entry Configuration
Required in NORTN-TACR
No
Yes
NORTN-TACR Element/Domain (Simple
Type)
Accepts Null Value
HospitalDCTime
Yes, common null values
Field Values

Relevant value for data element
Additional Information


Document as military time
Used to calculate field Total Length of Hospital Stay (which is the elapsed time from ED/Hospital Arrival to
Hospital Discharge)
Data Source Hierarchy
4
5
6
Hospital Record
Billing Sheet/Medical Records Coding Summary Sheet
Physician Discharge Summary
References to Other Databases


NTDS 1.2.5
OH-TACR
NORTN 2016 Revision
Page 138
HOSPITAL DISCHARGE DISPOSITION
Data Format is single-choice.
Definition
Hospital Discharge Disposition documents in general terms where the patient went after discharge from your
hospital.
NORTN-TACR Data Type
xs- integer
Multiple Entry Configuration
Required in NORTN-TACR
No
Yes
NORTN-TACR Element/Domain
(Simple Type)
Accepts Null Value
HospitalDcDispo
Yes, common null values
Field Values
1
2
3
4
5
6
7
8
9
10
11
12
13
14
Discharged/Transferred to another hospital for ongoing acute inpatient care
Discharged to an intermediate care facility (ICF)/long term care facility (LTCF)
Discharged/Transferred to home under the care of an organized home health service
Left against medical advice (AMA) or discontinued care
Died
Discharged home or self-care (routine discharge)
Discharged to a skilled nursing facility (SNF)
Discharged to hospice care
[value 9 not used]
Discharged to court/law enforcement/jail
Discharged to another type of inpatient rehabilitation facility (IRF)
Discharged to a long term acute care hospital (LTACH)
Discharged /transferred to psychiatric hospital/ psychiatric unit
Discharged/ transferred to other type of institution not listed here
Additional Information





In field values #3 and #6, “Home” refers to the patient’s current place of residence (e.g., home, prison, etc.)
Field values based upon UB-04 disposition coding
Disposition to any other non-medical facility should be coded as 6
Disposition to any other medical facility should be coded as 9
Refer to the glossary for definitions of facility types
Data Source Hierarchy
1
2
3
Hospital Discharge Summary Sheet
Nurses Notes
Case Manager/Social Services Notes
References to Other Databases


NTDS 1.2.5
OH-TACR
NORTN 2016 Revision
Page 139
INPATIENT TRANSFER TO HOSPITAL
Data Format is single-choice.
Definition
Inpatient Transfer to Hospital documents a subsequent hospital destination for the patient after inpatient admission
at your hospital. This includes transfers to inpatient rehabilitation facilities.
NORTN-TACR Data Type
xs- integer
Multiple Entry Configuration
Required in NORTN-TACR
No
Yes
NORTN-TACR Element/Domain (Simple
Type)
Accepts Null Value
DcDestination
Yes, common null values
Field Values

Four- digit hospital code assigned by the Ohio Department of Public Safety
Data Source Hierarchy
1
2
3
Discharge Summary
Progress Notes
Billing/Registration Sheet
References to Other Databases

OH-TACR
NORTN 2016 Revision
Page 140
LENGTH OF STAY
Data Format is numeric.
Definition
Length of Stay documents the total number of days that the patient occupied a bed while in your hospital.
NORTN-TACR Data Type
xs- integer
Multiple Entry Configuration
Required in NORTN-TACR
No
Yes
NORTN-TACR Element/Domain
(Simple Type)
Accepts Null Value
LengthOfStay
Field Values

Relevant value for data element
Additional Information


This field is calculated from data in the “Hospital Arrival Date” and “Discharge Date” fields.
Recorded in full day increments with any partial calendar day counted as a full calendar day.
Data Source Hierarchy
1 Registration Form
2 Discharge Form
References to Other Databases

OH-TACR
NORTN 2016 Revision
Page 141
DISCHARGE STATUS
Data Format is single-choice.
Definition
Discharge Status is whether the patient left your hospital alive or dead.
NORTN-TACR Data Type
xs- integer
Multiple Entry Configuration
Required in NORTN-TACR
No
Yes
NORTN-TACR Element/Domain
(Simple Type)
Accepts Null Value
Outcome
No
Field Values
1
2
Alive
Dead
Data Source Hierarchy
1
2
3
Discharge Summary
Progress Notes
Billing Sheet
References to Other Databases

OH-TACR
NORTN 2016 Revision
Page 142
TIME OF DEATH
Data Format is numeric.
Definition
Time of Death is the time of day that the patient was pronounced dead or time of declaration of brain death.
NORTN-TACR Data Type
xs-time
Multiple Entry Configuration
Required in NORTN-TACR
No
Yes
NORTN-TACR Element/Domain
(Simple Type)
Accepts Null Value
TimeOfDeath
Yes, common null values
Field Values

Relevant value for data element
Additional Information




Document as military time
Only complete field when Discharge Status is completed as Dead
This may differ from the time of discharge
Time of Death must be ≤ Hospital Discharge Time
Data Source Hierarchy
1
2
3
Hospital Record
Billing Sheet/Medical Records Coding Summary Sheet
Physician Discharge Summary
References to Other Databases

OH-TACR
NORTN 2016 Revision
Page 143
PRIMARY METHOD OF PAYMENT
Data Format is single-choice.
Definition
Primary Method of Payment is the patient’s foremost source of payment for care while in your hospital.
NORTN-TACR Data Type
xs- integer
Multiple Entry Configuration
Required in NORTN-TACR
No
Yes
NORTN-TACR Element/Domain
(Simple Type)
Accepts Null Value
PrimaryPayer
Yes, common null values
Field Values
1
2
3
4
5
6
7
8
9
10
Medicaid
Not Billed (for any reason)
Self Pay
Private/Commercial Insurance
No Fault Automobile Insurance (Retired 2016)
Medicare
Other Government Payer Source
Workers Compensation
Blue Cross/Blue Shield
Other
Additional Information


Examples of “Other Government Payer Source”: Veterans Affairs (VA), Champus, Tri Care, Champ VA.
Charity or HCAP should be coded under “Not Billed”
Data Source Hierarchy
1
2
Billing Sheet/Medical Records Coding Summary Sheet
Hospital Admission Form
References to Other Databases


NTDS 1.2.5
OH-TACR
NORTN 2016 Revision
Page 144
BILLED HOSPITAL CHARGES
Data Format is single-choice.
Definition
Billed Hospital Charges is the final dollar amount billed to the patient for this injury admission at your hospital
(excludes professional fees).
NORTN-TACR Data Type
xs-integer
Multiple Entry Configuration
Required in NORTN-TACR
No
Yes
NORTN-TACR Element/Domain
(Simple Type)
Accepts Null Value
Charges
Yes, common null values
Field Values

Whole dollar amount of total hospital charges rounded off to the nearest dollar
Data Source Hierarchy

Billing Sheet
References to Other Databases

NORTN field only
NORTN 2016 Revision
Page 145
ORGANS/TISSUE REQUESTED
Data Format is multiple-choice.
Definition
Organs/Tissue Requested is whether the local organ procurement organization (OPO) was contacted by your
hospital in regards to possible donation of the patient’s organs and/or tissues.
NORTN-TACR Data Type
xs- integer
Multiple Entry Configuration
Required in NORTN-TACR
No
Yes
NORTN-TACR Element/Domain
(Simple Type)
Accepts Null Value
OrganReq
Yes, common null values
Field Values
1
2
Yes
No
Additional Information

Select NA if the patient is alive
Data Source Hierarchy
1
2
3
Discharge Summary
History and Physical
Billing Sheet
References to Other Databases

NORTN field only
NORTN 2016 Revision
Page 146
AUTOPSY PERFORMED
Data Format is single-choice.
Definition
Autopsy Performed documents whether an internal organ exam was performed on the patient by a trained
pathologist.
NORTN-TACR Data Type
xs-integer
Multiple Entry Configuration
Required in NORTN-TACR
No
Yes
NORTN-TACR Element/Domain
(Simple Type)
Accepts Null Value
Autopsy
Yes, common null values
Field Values
1
2
Yes, an autopsy was performed
No, an autopsy was not performed
Additional Information

Select NA if the patient is alive
Additional Information

If only an external or visual-type exam was done and no internal organs were surgically explored, field value #2,
No, an autopsy was not performed, should be selected.
Data Source Hierarchy
1
2
Autopsy Report
Discharge Summary
References to Other Databases

OH-TACR
NORTN 2016 Revision
Page 147
HOSPITAL COMPLICATIONS
Data Format is multiple-choice.
Definition
Hospital Complications document any medical complication that occurred during the patient’s stay at your hospital.
NORTN-TACR Data Type
xs-integer
Multiple Entry Configuration
Required in NORTN-TACR
Yes, 25
Yes
NORNT-TACR Element/Domain
(Simple Type)
Accepts Null Value
Complications
Yes, common null values
Field Values
0
1
4
5
8
No Complications
Complications occurred that are otherwise not on this list
Acute kidney injury
Acute lung injury/ Acute respiratory distress syndrome
(ARDS)
Cardiac arrest with CPR
11
12
13
14
15
16
18
19
20
Decubitus ulcer
Deep surgical site infection
Drug or alcohol withdrawal syndrome
Deep Vein Thrombosis (DVT) / thrombophlebitis
Extremity compartment syndrome
Graft/ prosthesis/ flap failure (Retired 2016)
Myocardial infarction
Organ/ space surgical site infection
Pneumonia (Retired 2016)
21 Pulmonary Embolism
22 Stroke/ CVA
23 Superficial surgical site infection
25 Unplanned intubation
27 Urinary tract infection (Retired 2016)
28 Catheter- related blood stream infection
(Retired 2016)
29 Osteomyelitis
30 Unplanned return to the OR
31 Unplanned return to the ICU
32 Severe Sepsis
33 Catheter – associated urinary tract infection
(CAUTI)
34 Central line- associated bloodstream
Infection (CLABSI)
35 Ventilator- associated pneumonia (VAP)
Additional Information



The Field Value #1, Complications occurred that are otherwise not on this list, is chosen if that patient had a complication
but it is not included in the list here. The list here mirrors the NTDS list of tracked patient complications.
The field value #0, No Complications, should be used for patients with no medical complications as a result of this injury
episode.
See Appendix B – Hospital Complications for field value definitions
Data Source Hierarchy
1
2
3
Discharge Summary
History and Physical
Billing Sheet
References to Other Databases


NTDS 1.2.5
OH-TACR
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GLOSSARY OF TERMS
Discharge Disposition
Field
Value
Variable
Definition
2
Intermediate Care
Facility (ICF)
A nursing home providing long-term care less than a skilled level, usually custodial care only.
7
Skilled Nursing
Facility (SNF)
A nursing home or unit which provides skilled nursing or rehabilitation care, less than the
level of an inpatient rehabilitation facility.
8
Hospice
A special way of caring for persons who are terminally ill. Hospice services can be provided in
the home or at a nursing facility.
9
Inpatient
Rehabilitation Facility
(IRF)
A hospital or part of a hospital which provides intensive (3 hours per day) of rehabilitation
therapies to persons with disability from recent injury or illness.
10
Long Term Acute
Care Hospital
(LTACH)
A special hospital or part of a hospital that provides treatment for patients who stay, on
average, more than 25 days for extended acute care. Most patients are transferred from an
intensive or critical care unit.
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APPENDIX A - CO-MORBID CONDITIONS
Field
Value
2
Variable
Alcohol Use
Disorder
4
Bleeding
disorder
5
Currently
receiving
Chemotherap
y for Cancer
6
Congenital
Anomaly
7
Congestive
Heart Failure
(CHF)
Definition
(Consistent with APA DSM 5): Diagnosis of alcohol use disorder documented in the patient medical
record.
Any condition that places the patient at risk for bleeding in which there is a problem with the body’s
blood clotting process (e.g., vitamin K deficiency, hemophilia, thrombocytopenia, chronic
anticoagulation therapy with Coumadin, Plavix, or similar medications.) Do not include patients on
chronic aspirin therapy. The following is a list of medications that impact the patient’s risk for
bleeding. Please utilize the associated time frames for discontinuation of medication prior to
determine your answer to this variable.
Medication
Time Frame
Coumadin (warfarin)
5 days
Heparin (IV only)
4 hours
Plavix (clopidogrel)
10 days
Ticlid (ticlopidine)
14 days
Lovenox (enoxaparin)
12 hours
Reopro (abciximab)
9 days
Integrilin (eptifibatide)
2 days
Agrylin (anagrelide)
3 days
Fragmin (dalteparin)
24 hours
Aggrastat (triofiban)
4 hours
Pradaxa (dabigatran etexilate)
2 days
Xarelto (rivaroxaban)
2 days
A patient who is currently receiving any chemotherapy treatment for cancer prior to admission.
Chemotherapy may include, but is not restricted to, oral and parenteral treatment with
chemotherapeutic agents for malignancies such as colon, breast, lung, head and neck, and
gastrointestinal solid tumors as well as lymphatic and hematopoietic malignancies such as
lymphoma, leukemia, and multiple myeloma. Do not include if treatment consists solely of hormonal
therapy.
Defined as documentation of a cardiac, pulmonary, body wall, CNS/spinal, GI, renal, orthopedic, or
metabolic congenital anomaly.
Defined as the inability of the heart to pump a sufficient quantity of blood to meet the metabolic
needs of the body or can do so only at an increased ventricular filling pressure. To be included, this
condition must be noted in the medical record as CHF, congestive heart failure, or pulmonary edema
with onset or increasing symptoms within 30 days prior to injury.
Common manifestations are:
1. Abnormal limitation in exercise tolerance due to dyspnea or fatigue
2. Orthopnea (dyspnea on lying supine)
3. Paroxysmal nocturnal dyspnea (awakening from sleep with dyspnea)
4. Increased jugular venous pressure
5. Pulmonary rales on physical examination
6. Cardiomegaly
7. Pulmonary vascular engorgement
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8
Current
Smoker
9
Chronic Renal
Failure
10
CVA/residual
neurological
deficit
11
Diabetes
Mellitus
A patient who reports smoking cigarettes every day or some days. Excludes patients who smoke
cigars or pipes or use smokeless tobacco (chewing tobacco or snuff).
Acute or chronic renal failure prior to injury that was requiring periodic peritoneal dialysis,
hemodialysis, hemofiltration, or hemodiafiltration. (Excludes transplant patients)
A history prior to injury of a cerebrovascular accident (embolic, thrombotic, or hemorrhagic) with
persistent residual motor sensory or cognitive dysfunction. (E.g., hemiplegia, hemiparesis, aphasia,
sensory deficit, impaired memory).
Diabetes mellitus prior to injury that required exogenous parenteral insulin or an oral hypoglycemic
agent. Do not include a patient if diabetes is controlled by diet alone.
Patients who have cancer that:
12
Disseminated
Cancer
1. Has spread to one site or more sites in addition to the primary site AND
2. In whom the presence of multiple metastases indicates the cancer is widespread, fulminant,
or near terminal. Other terms describing disseminated cancer include “diffuse,” “widely
metastatic,” “widespread,” or “carcinomatosis.” Common sites of metastases include major
organs (e.g., brain, lung, liver, meninges, abdomen, peritoneum, pleura, and bone).
Report Acute Lymphocytic Leukemia (ALL), Acute Myelogenous Leukemia (AML), and Stage IV
Lymphoma under this variable. Do NOT report Chronic Lymphocytic Leukemia (CLL), Chronic
Myelogenous Leukemia (CML), Stages I through III Lymphoma, or Multiple Myeloma as disseminated
cancer.
13
Advanced
Directive
Limiting Care
The patient had a Do Not Resuscitate (DNR) document or similar advance directive recorded prior to
injury.
Pre-injury functional status may be represented by the ability of the patient to complete activities of
daily living (ADL) including: bathing, feeding, dressing, toileting, and walking. This item is marked YES
if the patient, prior to injury, was partially dependent or completely dependent upon equipment,
devices or another person to complete some or all activities of daily living.
Formal definitions of dependency are listed below:
15
16
Functionally
dependent
health status
History of
angina within
past 1 month
1. Partially dependent: The patient requires the use of equipment or devices coupled with
assistance from another person for some activities of daily living. Any patient coming from a
nursing home setting who is not totally dependent would fall into this category, as would
any patient who requires kidney dialysis or home ventilator support that requires chronic
oxygen therapy yet maintains some independent functions.
2. Totally dependent: The patient cannot perform any activities of daily living for
himself/herself. This would include a patient who is totally dependent upon nursing care, or
a dependent nursing home patient. All patients with psychiatric illnesses should be
evaluated for their ability to function with or without assistance with ADLs just as the nonpsychiatric patient.
Pain or discomfort between the diaphragm and the mandible resulting from myocardial ischemia.
Typically angina is a dull, diffuse (fist sized or larger) substernal chest discomfort precipitated by
exertion or emotion and relieved by rest or nitroglycerine. Radiation often occurs to the arms and
shoulders and occasionally to the neck, jaw (mandible, not maxilla), or interscapular region. For
patients on anti-anginal medications, enter yes only if the patient has had angina within one month
prior to admission.
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17
History of
Myocardial
Infarction (MI)
18
History of
Peripheral
Vascular
Disease (PVD)
19
Hypertension
requiring
medication
21
Prematurity
23
Respiratory
Disease
The history of a non-Q wave, or a Q wave infarction in the six months prior to injury as diagnosed in
the patient's medical record.
(History of peripheral vascular disease): Any type of operative (open) or interventional radiology
angioplasty or revascularization procedure for atherosclerotic PVD (e.g., aorta-femoral, femoralfemoral, femoral-popliteal, balloon angioplasty, stenting, etc.). Patients who have had amputation for
trauma or resection/repair of abdominal aortic aneurysms, including Endovascular Repair of
Abdominal Aortic Aneurysm (EVAR), would not be included.
History of a persistent elevation of systolic blood pressure >140 mm Hg and a diastolic blood pressure
>90 mm Hg requiring an antihypertensive treatment (e.g., diuretics, beta blockers, angiotensinconverting enzyme (ACE) inhibitors, calcium channel blockers). History of hypertension prior to injury
must be documented in the patient’s chart.
Defined as documentation of premature birth, a history of bronchopulmonary dysplasia, or ventilator
support for greater than 7 days after birth. Premature birth is defined as infants delivered before 37
weeks from the first day of the last menstrual period.
Defined as severe chronic lung disease, chronic asthma, cystic fibrosis, or chronic obstructive
pulmonary disease (COPD) such as emphysema and/or chronic bronchitis resulting in any one or more
of the following:
1. Functional disability from COPD (e.g., dyspnea, inability to perform activities of daily living
[ADLs])
2. Hospitalization in the past for treatment of COPD
3. Requires chronic bronchodilator therapy with oral or inhaled agents
4. A Forced Expiratory Volume in 1 second (FEV1) of <75% of predicted on pulmonary function
testing
Do not include patients whose only pulmonary disease is acute asthma. Do not include patients with
diffuse interstitial fibrosis or sarcoidosis.
Patients that required the regular administration of oral or parenteral corticosteroid medications
(e.g., prednisone, dexamethasone in the 30 days prior to injury for a chronic medical condition (e.g.,
COPD, asthma, rheumatologic disease, rheumatoid arthritis, inflammatory bowel disease). Do not
include topical corticosteroids applied to the skin or corticosteroids administered by inhalation or
rectally.
Documentation in the medical record of cirrhosis, which might also be referred to as end stage liver
disease. If there is documentation of prior or present esophageal or gastric varices, portal
hypertension, previous hepatic encephalopathy, or ascites with notation of liver disease, then
cirrhosis should be considered present. Cirrhosis should also be considered present if documented
by diagnostic imaging studies or a laparotomy/laparoscopy.
24
Steroid use
25
Cirrhosis
26
Dementia
With particular attention to senile or vascular dementia (e.g. Alzheimer’s).
27
Major
Psychiatric
Illness
28
Drug Abuse or
Dependence
Defined as documentation of the presence of pre-injury major depressive disorder, bipolar disorder,
schizophrenia, anxiety / panic disorder, borderline or antisocial personality disorder, and / or
adjustment disorder / post-traumatic stress disorder.
With particular attention to opioid, sedative, amphetamine, cocaine, diazepam, alprazolam, or
lorazepam dependence (excludes ADD / ADHD or chronic pain with medication use as-prescribed).
30
Attention
deficit
disorder/Atte
History of a disorder involving inattention, hyperactivity or impulsivity requiring medication for
treatment.
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ntion deficit
hyperactivity
disorder
(ADD/ADHD)
50
Osteoporosis
51
Hearing
Impaired
52
Vision
Impairment
53
Language
Barrier
Thinning of bone tissue and loss of bone density over time; most common in post-menopausal
women.
Impairment of the sense of hearing.
Vision impairments result from conditions that range from the presence of some usable vision, low
vision, to the absence of any vision, total blindness. Low vision is a term that describes a person with
a vision impairment that cannot be improved by correction but has some usable vision remaining.
Barrier to communication resulting from speaking different languages
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APPENDIX B – Hospital Complications
Variable
4
Acute Kidney Injury
Definition
A patient who did not require chronic renal replacement therapy prior to injury, who has worsening renal dysfunction after
injury requiring renal replacement therapy. If the patient or family refuses treatment (e.g., dialysis), the condition is still
considered to be present if a combination of oliguria and creatinine are present.
GFR criteria: Increase creatinine x3 or GFR decrease > 75%
Urine output criteria: UO < 0.3ml/kg/h x 24 hr or Anuria x 12 hrs
5
Acute Lung Injury/
Acute Respiratory
Distress Syndrome
(ARDS)
8
Cardiac Arrest with
CPR
11
Decubitus Ulcer
ALI/ARDS occurs in conjunction with catastrophic medical conditions, such as pneumonia, shock, sepsis (or severe infection
throughout the body, sometimes also referred to as systemic infection, and may include or also be called a blood or bloodborne infection), and trauma. It is a form of sudden and often severe lung failure that is usually characterized by a PaO2 / FiO2
ratio of < 300 mmHg, bilateral fluffy infiltrates seen on a frontal chest radiograph, and an absence of clearly demonstrable
volume overload (as signified by pulmonary wedge pressure < 18 mmHg, if measured, or other similar surrogates such as
echocardiography which do not demonstrate analogous findings).
The sudden abrupt loss of cardiac function that results in loss of consciousness requiring the initiation of any component of
basic and/or advanced cardiac life support. Excludes patients that arrive at the hospital in full arrest.
Defined as any partial or full thickness loss of dermis resulting from pressure exerted by the patient’s weight against a surface.
Deeper tissues may or may not be involved. Equivalent to NPUAP Stages II – IV and NPUAP “unstageable” ulcers.
EXCLUDES intact skin with nonblanching redness (NPUAP Stage I), which is considered reversible tissue injury.
Defined as a deep incisional SSI must meet one of the following criteria:
1.
12
Deep Surgical Site
Infection
Infection occurs within 30 days after the operative procedure if no implant is left in place or within one year if implant
is in place and the infection appears to be related to the operative procedure and involves deep soft tissues (e.g.,
fascial and muscle layers) of the incision
AND patient has at least one of the following:
1. purulent drainage from the deep incision but not from the organ/space component of the surgical site of the
following:
2. a deep incision spontaneously dehisces or is deliberately opened by a surgeon and is culture-positive or not cultured
when the patient has at least one of the following signs or symptoms: fever (>38°C), or localized pain or tenderness. A
culture-negative finding does not meet this criterion.
3. an abscess or other evidence of infection involving the deep incision is found on direct examination, during
reoperation, or by histopathologic or radiologic examination
4. diagnosis of a deep incisional SSI by a surgeon or attending physician.
NOTE: There are two specific types of deep incisional SSIs:
1. Deep Incisional Primary (DIP)- a deep incisional SSI that is identified in a primary incision in a patient that has had an
operation with one or more incisions (e.g., C-section incision or chest incision for CBGB)
2. Deep Incisional Secondary (DIS)-a deep incisional SSI that is identified in the secondary incision in a patient that has had an
operation with more than one incision (e.g., donor site [leg] incision for CBGB)
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REPORTING INSTRUCTIONS:
• Classify infection that involves both superficial and deep incision sites as deep incisional SSI.
Defined as a set of symptoms that may occur when a person who has been habitually drinking too much alcohol or habitually
using certain drugs (e.g. narcotics, benzodiazepine) experiences physical symptoms upon suddenly stopping consumption.
Symptoms may include: activation syndrome (i.e., tremulousness, agitation, rapid heart beat and high blood pressure),
seizures, hallucinations or delirium tremens.
13
Drug or Alcohol
Withdrawal
Syndrome
14
Deep Vein
Thrombosis (DVT)/
Thrombophlebitis
15
Extremity
Compartment
Syndrome
Defined as a condition not present at admission in which there is documentation of tense muscular compartments of an
extremity through clinical assessment or direct measurement of intracompartmental pressure) requiring fasciotomy.
Compartment syndromes usually involve the leg but can also occur in the forearm, arm, thigh, and shoulder. Record as a
complication if it is originally missed, leading to late recognition, a need for late intervention, and has threatened limb viability.
18
Myocardial Infarction
A new acute myocardial infarction occurring during hospitalization (within 30 days of injury).
Organ/ Space
Surgical Site Infection
Defined as an infection that occurs within 30 days after an operation and infection involves any part of the anatomy (e.g.,
organs or spaces) other than the incision, which was opened or manipulated during a procedure; and at least one of the
following, including:
1. Purulent drainage from a drain that is placed through a stab wound or puncture into the organ/space;
2. Organisms isolated from an aseptically obtained culture of fluid or tissue in the organ/space;
3. An abscess or other evidence of infection involving the organ/space that is found on direct examination, during
reoperation, or by histopathologic or radiologic examination; or
4. Diagnosis of an organ/space SSI by a surgeon or attending physician.
19
21
Pulmonary Embolism
 The formation, development, or existence of a blood clot or thrombus within the vascular system, which may be coupled
with inflammation. This diagnosis may be confirmed by a venogram, ultrasound, or CT. The patient must be treated with
anticoagulation therapy and/or placement of a vena cava filter or clipping of the vena cava.
 Defined as a lodging of a blood clot in a pulmonary artery with subsequent obstruction of blood supply to the lung
parenchyma. The blood clots usually originate from the deep leg veins or the pelvic venous system. Consider the condition
present if the patient has a V-Q scan interpreted as high probability of pulmonary embolism or a positive pulmonary
arteriogram or positive CT angiogram.
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A focal or global neurological deficit of rapid onset and NOT present on admission. The patient must have at least one of the
following symptoms:
22
Stroke/ CVA
1.
2.
3.
4.
5.
6.
7.
8.
AND


AND

AND

Change in level of consciousness,
Hemiplegia,
Hemiparesis,
Numbness or sensory loss affecting one side of the body,
Dysphasia or aphasia,
Hemianopia
Amaurosis fugax,
Or other neurological signs or symptoms consistent with stroke
Duration of neurological deficit ≥24 h
OR duration of deficit <24 h, if neuroimaging (MR, CT, or cerebral angiography) documents a new hemorrhage or
infarct consistent with stroke, or therapeutic intervention(s) were performed for stroke, or the neurological deficit
results in death
No other readily identifiable nonstroke cause, e.g., progression of existing traumatic brain injury, seizure, tumor,
metabolic or pharmacologic etiologies, is identified
Diagnosis is confirmed by neurology or neurosurgical specialist or neuroimaging procedure (MR, CT, and angiography)
or lumbar puncture (CSF demonstrating intracranial hemorrhage that was not present on admission).
Although the neurologic deficit must not present on admission, risk factors predisposing to stroke (e.g., blunt cerebrovascular
injury, dysrhythmia) may be present on admission.
Defined as an infection that occurs within 30 days after an operation and infection involves only skin or subcutaneous tissue of
the incision and at least one of the following:
23
Superficial Surgical
Site Infection
1. Purulent drainage, with or without laboratory confirmation, from the superficial incision.
2. Organisms isolated from an aseptically obtained culture of fluid or tissue from the superficial incision.
3. At least one of the following signs or symptoms of infection: pain or tenderness, localized swelling, redness, or heat
and superficial incision is deliberately opened by the surgeon, unless incision is culture-negative.
4. Diagnosis of superficial incisional surgical site infection by the surgeon or attending physician.
Do not report the following conditions as superficial surgical site infection:
1. Stitch abscess (minimal inflammation and discharge confined to the points of suture penetration).
2. Infected burn wound.
3. Incisional SSI that extends into the fascial and muscle layers (see deep surgical site infection).
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25
Unplanned
Intubation
Patient requires placement of an endotracheal tube and mechanical or assisted ventilation because of the onset of respiratory
or cardiac failure manifested by severe respiratory distress, hypoxia, hypercarbia, or respiratory acidosis. In patients who were
intubated in the field or Emergency Department, or those intubated for surgery, unplanned intubation occurs if they require
reintubation > 24 hours after extubation.
Defined as meeting at least one of the following criteria:
1.
2.
29
Osteomyelitis
30
Unplanned Return to

the OR
31
Unplanned Return to
the ICU
32
Severe Sepsis
33
Catheter-associated
Urinary Tract
Infection
3.
Organisms cultured from bone.
Evidence of osteomyelitis on direct examination of the bone during a surgical operation or histopathologic
examination.
At least two of the following signs or symptoms with no other recognized cause: fever (38° C), localized swelling,
tenderness, heat, or drainage at suspected site of bone infection and at least one of the following:
a. Organisms cultured from blood
b. Positive blood antigen test (e.g., H. influenzae, S. pneumoniae)
c. Radiographic evidence of infection, e.g., abnormal findings on x-ray, CT scan, magnetic resonance imaging
(MRI), radiolabel scan (gallium, technetium, etc.).
Unplanned return to the operating room after initial operation management for a similar or related previous procedure.
Unplanned return to the intensive care unit after initial ICU discharge. Does not apply if ICU care is required for postoperative
care of a planned surgical procedure.
Defined as an obvious source of infection with bacteremia and two or more of the following:
1. Temp > 38 degrees C or < 36 degrees C
2. White Blood Cell count > 12,000/mm³, or >20% immature (Source of Infection)
3. Hypotension – (Severe Sepsis)
4. Evidence of hypoperfusion: (Severe Sepsis)
A. Anion gap or lactic acidosis or
B. Oliguria, or
C. Altered mental status
(Consistent with the January 2015 CDC defined CAUTI): A UTI where an indwelling urinary catheter was in place for >2 calendar
days on the date of event, with day of device placement being Day 1,
AND
An indwelling urinary catheter was in place on the date of event or the day before. If an indwelling urinary catheter was in
place for >2 calendar days and then removed, the date of event for the UTI must be the day of discontinuation or the next
day for the UTI to be catheter-associated.
CAUTI Criterion SUTI 1a:
Patient must meet 1, 2, and 3 below:
1. Patient has an indwelling urinary catheter in place for the entire day on the date of event and such catheter had been in
place for >2 calendar days, on that date (day of device placement = Day 1)
2. Patient has at least one of the following signs or symptoms:
• Fever (>38⁰C)
• Suprapubic tenderness with no other recognized cause
• Costovertebral angle pain or tenderness with no other recognized cause
3. Patient has a urine culture with no more than two species of organisms, at least one of which is a bacteria >10⁵ CFU/ml.
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34
Central lineassociated
bloodstream
infection
OR
Patient must meet 1, 2, and 3 below:
1. Patient had an indwelling urinary catheter in place for >2 calendar days wich was removed on the day of, or day before the
date of event.
2. Patient has at least one of the following signs or symptoms:
• fever (>38⁰C)
• suprapubic tenderness with no other recognized cause
• costovertebral angle pain or tenderness with no other recognized cause
• urinary urgency with no other recognized cause
• urinary frequency with no other recognized cause
• dysuria with no other recognized cause
3. Patient has a urine culture with no more than two species of organisms, at least one of which is a bacteria >10⁵ CFU/ml.
CAUTI Criterion SUTI 2:
Patient must meet 1, 2 and 3 below:
1. Patient is ≤1 year of age
2. Patient has at least one of the following signs or symptoms:
• fever (>38.0⁰C)
• hypothermia (<36.0⁰C)
• apnea with no other recognized cause
• bradycardia with no other recognized cause
• lethargy with no other recognized cause
• vomiting with no other recognized cause
• suprapubic tenderness with no other recognized cause
3. Patient has a urine culture with no more than two species of organisms, at least one of which is bacteria of ≥10⁵ CFU/ml.
(Consistent with the January 2014 CDC Defined CLABSI): A laboratory-confirmed bloodstream infection (LCBI) where central
line (CL) or umbilical catheter (UC) was in place for >2 calendar days on the date of event, with day of device placement
being Day 1,
AND
A CL or UC was in place on the date of event or the day before. If a CL or UC was in place for >2 calendar days and then
removed, the LCBI criteria must be fully met on the day of discontinuation or the next day. If the patient is admitted or
transferred into a facility with a central line in place (e.g., tunneled or implanted central line), and that is the patient’s only
central line, day of first access as an inpatient is considered Day 1. “Access” is defined as line placement, infusion or
withdrawal through the line.
January 2014 CDC Criterion LCBI 1:
Patient has a recognized pathogen cultured from one or more blood cultures
AND
Organism cultured from blood is not related to an infection at another site
OR
January 2014 CDC Criterion LCBI 2:
Patient has at least one of the following signs or symptoms: fever (>38⁰C), chills, or hypotension
AND
positive laboratory results are not related to an infection at another site
AND
the same common commensal (i.e., diphtheroids [Corynebacterium spp. not C. diphtheriae], Bacillus spp. [not B. anthracis],
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Propionibacterium spp., coagulase-negative staphylococci [including S. epidermidis], viridans group streptococci,
Aerococcus spp., and Micrococcus spp.) is cultured from two or more blood cultures drawn on separate occasions.
Criterion elements must occur within a timeframe that does not exceed a gap of 1 calendar day between two adjacent
elements
OR
January 2014 CDC Criterion LCBI 3:
Patient ≤ 1 year of age has at least one of the following signs or symptoms: fever (>38⁰ C core), hypothermia (<36⁰C core),
apnea, or bradycardia
AND
positive laboratory results are not related to an infection at another site
AND
the same common commensal (i.e., diphtheroids [Corynebacterium spp. not C. diphtheriae], Bacillus spp. [not B. anthracis],
Propionibacterium spp., coagulase-negative staphylococci [including S. epidermidis], viridans group streptococci,
Aerococcus spp., Micrococcus spp.) is cultured from two or more blood cultures drawn on the same or consecutive days
and separate occasions. Criterion elements must occur within a timeframe that does not exceed a gap of 1 calendar day
between two adjacent elements.
(Consistent with the January 2015 CDC Defined VAP): A pneumonia where the patient is on mechanical ventilation for >2
calendar days on the date of event, with day of ventilator placement being Day 1,
AND
The ventilator was in place on the date of event or the day before. If the patient is admitted or transferred into a facility on a
ventilator, the day of admission is considered Day 1.
(See next page for algorithms)
35
Ventilator-associated
Pneumonia
VAP Algorithm (PNU2 Bacterial or Filamentous Fungal Pathogens):
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RADIOLOGY
Two or more serial chest
radiographs with at least one of
the following:
SIGNS/SYMPTOMS
At least one of the following:
LABORATORY
At least one of the following:
• Fever (>38⁰C or >100.4⁰F)
• New or progressive and
persistent infiltrate
• Leukopenia (<4000 WBC/mmᵌ)
or leukocytosis (≥12,000
WBC/mmᵌ)
• Positive growth in blood culture
not related to another source of
infection
• Consolidation
• Cavitation
• Pneumatoceles, in infants ≤1
year old
NOTE: In patients without
underlying pulmonary or cardiac
disease (e.g., respiratory distress
syndrome, bronchopulmonary
dysplasia, pulmonary edema, or
chronic obstructive pulmonary
disease), one definitive chest
radiograph is acceptable.
• For adults ≥70 years old, altered
mental status with no other
recognized cause
AND at least two of the following:
• New onset of purulent sputum,
or change in character of sputum,
or increased respiratory
secretions, or increased suctioning
requirements
• New onset or worsening cough,
or syspnea, or tachypnea
• Rales or bronchial breath sounds
• Worsening gas exchange (e.g., 0₂
desaturations (e.g.,
PaO₂/FiO₂≤240), increased oxygen
requirements, or increased
ventilator demand)
• Positive growth in culture of
pleural fluid
• Positive quantitative culture
from minimally-contaminated LRT
specimen (e.g., BAL or protected
specimen brushing)
• ≥5% BAL-obtained cells contain
intracellular bacteria on direct
microscopic exam (e.g., Gram’s
stain)
• Positive quantitative culture of
lung tissue
• Histopathologic exam shows at
least one of the following
evidences of pneumonia:
o Abscess formation or foci of
consolidation with intense PMN
accumulation in bronchioles and
alveoli
o Evidence of lung parenchyma
invasion by fungal hyphae or
pseudohyphae
(See next page for algorithms)
VAP Algorithm (PNU2 Viral, Legionnella, and other Bacterial Pneumonias):
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RADIOLOGY
Two or more serial chest
radiographs with at least one of
the following:
SIGNS/SYMPTOMS
At least one of the following:
LABORATORY
At least one of the following:
• Fever (>38⁰C or >100.4⁰F)
• New or progressive and
persistent infiltrate
• Leukopenia (<4000 WBC/mmᵌ)
or leukocytosis (≥12,000
WBC/mmᵌ)
• Positive culture of virus,
Legionella or Chlamydia from
respiratory secretions
• Consolidation
• Cavitation
• Pneumatoceles, in infants ≤1
year old
NOTE: In patients without
underlying pulmonary or cardiac
disease (e.g., respiratory distress
syndrome, bronchopulmonary
dysplasia, pulmonary edema, or
chronic
• For adults ≥70 years old, altered
mental status with no other
recognized cause
AND at least two of the following:
• New onset of purulent sputum,
or change in character of sputum,
or increased respiratory
secretions, or increased suctioning
requirements
• New onset or worsening cough,
• Positive non culture diagnostic
laboratory test of respiratory
secretions or tissue for virus,
Bordetella, Chylamydia,
Mycoplasma, Legionella (e.g., EIA<
FAMA< shell vial assay, PCR,
micro-IF)
• Fourfold rise in pared sera (IgG)
for pathogen (e.g., influenza
viruses, Chlamydia)
• Fourfold rise in L. pneumophila
serogroup 1 antibody titer to
≥1:128 in pared acute and
convalescent sera by indirect IFA.
• Detection of Legionella
pneumophila serogroup 1 antigens
in urine by RIA or EIA
VAP Algorithm ALTERNATE CRITERIA (PNU1), for infant’s ≤1 year old:
RADIOLOGY
Two or more serial chest radiographs with at least
one of the following:
• New or progressive and persistent infiltrate
SIGNS/SYMPTOMS
Worsening gas exchange (e.g., O₂ desaturation
[e.g. pulse oximetry <94%], increased oxygen
requirements, or increased ventilator demand)
AND at least three of the following:
• Temperature instability
• Consolidation
• Cavitation
• Leukopenia (<4000 WBC/mmᵌ) or leukocytosis
(≥15,000 WBC/mmᵌ) and left shift (≥10% band
forms)
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• Pneumatoceles, in infants ≤1 year old
NOTE: In patients without underlying pulmonary
or cardiac disease (e.g., respiratory distress
syndrome, bronchopulmonary dysplasia,
pulmonary edema, or chronic obstructive
pulmonary disease), one definitive chest
radiograph is acceptable.
• New onset of purulent sputum, or change in
character of sputum, or increased respiratory
secretions, or increased suctioning requirements
• Apnea, tachypnea, nasal flaring with retraction
of chest wall, or nasal flaring with grunting
• Wheezing, rales, or rhonchi
• Cough
• Bradycardia (<100 beats/min) or tachycardia
(>170 beats/min)
VAP Algorithm ALTERNATE CRITERIA (PNU1), for children >1 year old or ≤12 years old:
RADIOLOGY
Two or more serial chest radiographs with at least
one of the following:
• New or progressive and persistent infiltrate
• Consolidation
• Cavitation
• Pneumatoceles, in infants ≤1 year old
NOTE: In patients without underlying pulmonary
or cardiac disease (e.g., respiratory distress
syndrome, bronchopulmonary dysplasia,
pulmonary edema, or chronic obstructive
pulmonary disease), one definitive chest
radiograph is acceptable
SIGNS/SYMPTOMS/LABORATORY
At least three of the following:
• Fever (>38.0⁰C or >100.4⁰F) or hypothermia
(<36.0⁰C or <96.8⁰F)
• Leukopenia (<4000 WBC/mmᵌ) or leukocytosis
(≥15,000 WBC/mmᵌ)
• New onset of purulent sputum, or change in
character of sputum, or increased respiratory
secretions, or increased suctioning requirements
• New onset or worsening cough, or dyspnea,
apnea, or tachypnea
• Rales or bronchial breath sounds
• Worsening gas exchange (e.g., O₂ desaturations
[e.g., pulse oximetry <94%], increased oxygen
requirements, or increased ventilator demand)
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GLOSSARY OF ABBREVIATIONS
ACE
ACS
ADL
AIS
ARDS
ARF
BMI
BP
CDC
CHF
CPAP/BIPAP
CT
CVA
DNR
DNR-CC
DNR-CCA
DVT
EOA
ED
EMS
FAST
FIPS
GCS
ICD-9-CM
IgG
ISS
LMA
MI
MRI
MMDDYYYY
NHTSA
NTDS
OPO
OR
OTR
PT
PTT
PVD
SaO2
TACR
UB-04
XML
xs-string
YYYY
Angiotensin Converting Enzyme
Abdominal compartment syndrome; American College of Surgeons
Activities of daily living
Abbreviated Injury Scale
Acute respiratory distress syndrome
Acute Renal Failure
Body mass index
Blood pressure
Centers for Disease Control and Prevention
Congestive heart failure
Continuous positive airway pressure/variable bi-level positive airway pressure
Computerized topography
Cerebral vascular accident
Do not resuscitate
Do not resuscitate; comfort care only
Do not resuscitate; comfort care arrest
Deep vein thrombosis
Esophageal Obturator Airway
Emergency department
Emergency medical services
Focused assessment with sonography for trauma
Federal Information Processing Standard codes
Glasgow Coma Score
International Classification of Diseases, Ninth Revision, Clinical Modification
Immunoglobulin G
Injury Severity Score
Laryngeal Mask Airway
Myocardial infarction
Magnetic resonance imaging
Date designation that represents the month in two digits followed by the day of the month in two digits,
followed by the year in four digits
National Highway Traffic Safety Administration
National Trauma Data Standard
Organ Procurement Organization
Operating Room
Ohio Trauma Registry
Prothrombin time
Partial thromboplastin time
Peripheral vascular disease
Saturation of oxygen in arterial blood
Trauma Acute Care Registry
Uniform Billing Form-04
Extensible Markup Language - Schema definition
XML schema defining the acceptable layout (commas, spaces, carriage returns, etc.)
Year designation that is represented in four digits, e.g. 2010
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CHANGE LOG
December 2015
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Additional icd-10 external cause code field added
Icd-10 place of occurrence code field added
Primary icd-10 external cause code field added
Report of physical abuse field added
Investigation of physical abuse field added
Caregiver at discharge field added
Scene interventions field added
Trauma center criteria field added
Vehicular, pedestrian, other risk injury field added
Prehospital cardiac arrest field added
Hospital procedures icd-10 field added
Injury diagnoses icd-10 field added
Initial field intubation, Initial field CPR, Initial field needle chest decompression or thoracostomy fields deleted and are included in scene
interventions field
Updated “references to other databases” for each field
Cause Code Field – added Fall.Minor and Fall.Major
Incident street address Field – added in Definition – Including street number (effective 3rd qtr. Submissions)
Incident street address Field - added in the additional information - If the incident occurred at the patients home, put the specific street
address of the patients home (effective 3rd qtr. Submissions)
Trauma type Field – added to thermal field value - Burn/ Cold
Trauma type Field – removed not applicable from “Other” field value
2016
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Removed ICD-9 codes from inclusion criteria
Removed ICD-9 codes from exclusion criteria
Removed ICD-9 codes from inclusion/exclusion decision tree and mirrored Ohio decision tree
Alternate home residence: Retired 4) Foreign Visitor and removed additional information pertaining to foreign visitor
Age Units – added field value 5) Minutes
Removed fields Primary Cause Code and Additional Cause code pertaining to ICD9
Removed location E-code pertaining to ICD9
Transport Agency- Updated additional information to include “other transport mode”
Initial ED/Hospital Temperature – Fahrenheit changed to Celsius
Initial field GCS – Total – added “If a patient does not have a numeric GCS recorded, but there is documentation related to their level of
consciousness such as "AAOx3," "awake alert and oriented," or "patient with normal mental status," interpret this as GCS of 15 IF there is
no other contradicting documentation.”
Initial ED/Hospital GCS – Total – added “If a patient does not have a numeric GCS recorded, but there is documentation related to their
level of consciousness such as "AAOx3," "awake alert and oriented," or "patient with normal mental status," interpret this as GCS of 15 IF
there is no other contradicting documentation.”
ED Discharge Written Date – field added
ED Discharge Written Time – field added
ED transfer to hospital – added to field values “Four- digit hospital code assigned by the Ohio Department of Public Safety” removed
“refer to Appendix 1-A for the list of hospital codes”
Transferring hospital code – added to field values “Four- digit hospital code assigned by the Ohio Department of Public Safety” removed
“refer to Appendix 1-A for the list of hospital codes”
Drug use indicator – added prescription and illegal drug and “illegal use drug includes illegal use of prescription drugs”
Hospital Procedure Code – Removed ICD9 codes form field values
Removed - Hospital Procedure code ICD9
Comorbid Conditions – updated #2 Alcoholism to Alcohol use disorder, retired: removed esophageal varices,
Removed - Injury Diagnoses ICD9
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2016 continued
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Hospital Discharge Written Date – field added
Hospital Discharge Written Time – field added
Hospital Discharge Disposition field – added to #6 self-care (routine discharge), removed #9 Discharged to another type of inpatient
rehabilitation facility (IRF), now “value 9 not used”, added values 11-14
Inpatient transfer to hospital – added to definition “This includes transfers to inpatient rehabilitation facilities” per OTR dictionary
Inpatient transfer to hospital – added to field values “Four- digit hospital code assigned by the Ohio Department of Public Safety”
removed “refer to Appendix 1-A for the list of hospital codes”
Time of death – added to definition “or time of declaration of brain death” per OTR dictionary
Primary method of Payment field – removed #5 – No fault insurance. Removed additional information pertaining to #5
Hospital Complications – Removed #16, 20, 27 and 28. Added # 33, 34 and 35
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