trauma room

In these situations, Height of Fall is recorded with an I for inappropriate. You can record any additional information you wish (excluding patient/provider specific information (PHI)) in the Cause of Injury Specify field.

This definition is very specific. Both the NTDS definition and PTOS definitions are consistent with the American Psychological Association (APA) DSM 5, 2013, and documentation of “depression” is not the same as the diagnosis of a major depressive disorder. The patient must have a diagnosis of a major depressive disorder OR received treatment for major …

Any previous head injury that caused anything from drowsiness to severe injury. When we say “A TBI must be clearly documented” this means any brain injury, so SDH qualifies. You do not need the actual text of “TBI”. You would often only see that wording if they don’t get a diagnosis.

The current definition for Advanced Directive Limited Care states “the patient had a written request limiting life-sustaining therapy, or similar advanced directive, present prior to arrival at your center.” If the refusal for blood products due to religious reasons was documented in the patient’s chart prior to arrival at your center, I recommend capturing this …

Please refer to the Best Practices Guidelines for abuse. If you cannot locate this resource, please contact PTSF staff, and we can provide it for you. I hope this document helps clarify abuse for you. This resource provides great information, and best practices for abstraction as well. Any physical assault is not abuse. However, according …

In situations where patients fall in place while going up steps, we recommend recording a fall height of 0 = fall on same level. This is only true if their fall did not result in a fall down the stairs. For mechanism in ICD-10, you will use the category for fall from/on stairs.

Mechanism of injury plays no role in the Pre-hospital Cardiac Arrest definition. This pre-existing condition should be considered for every PTOS patient regardless of their MOI or diagnoses.

That is correct. There must be documentation of the condition itself AND documentation of onset or increasing symptoms within 30 days prior to injury in order to include A.03-CHF as a PEC.

Yes, your example would meet Advanced Directive assuming it was either on the patient’s person on arrival, or already on file with your hospital. It must be a written request (not verbal), limiting life-sustaining therapy, and present on arrival or prior. The NTDB has listed Living Will has one example of an Advanced Directive; other …

In order to capture this as a pre-existing, the patient’s advanced directive to limit life-sustaining treatment must have been present on their person on arrival or already on file at your center.