trauma room

If there is no hormone medication documented, enter NO.  If there is hormone medication listed, and it is not document if it is gender affirming care, you are first directed to check with your physician/extender. If unable to determine, enter unknown. If the patient refuses to disclose, enter non-disclosed. 

With no documentation for gender, use unknown. Non-disclosed is reserved for the patient actually declining to answer, meaning I would expect to see documentation that they declined to answer.  I would also not assume and go with the same as sex. It is better to show that not everyone is collecting this, rather than fill …

No, legal sex may have been changed on documents from what was Sex Assigned at Birth.

Great question! This would not be considered a transport accident. To capture that (pedal cyclist injured in nontraffic accident), the device assigned primarily needs to be for conveying persons or goods from one place to another. Fall from one level to another would work best in this situation.

Hookah is not reported. The pre-existing condition Current Smoker excludes pipe, cigar, or smokeless tobacco (including vapes or e-cigarettes). Hookah is a type of pipe.

D.08 is not limited to the three listed, those are examples. I could not find the specific reference document on the ASH website either, but we’ve understood that this list is not all inclusive. The NTDB FAQ’s does tell us to report bleeding disorder for thrombocytopenia. It is for any condition where the blood does …

No, PTSF does not recommend capturing Functionally Dependent Health Status with documentation of a prosthetic eye as a prosthetic eye is more aesthetic than functional.

Per ICD-10 guidelines, SUV is included in the same category as pick-up truck or van. Although Jeep is not specifically defined in ICD-10, I recommend including Jeeps in the SUV/pick-up truck or van category.

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.

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.