trauma room

I would look for the hospital documentation first, using the latest time from the hospital, and using EMS time if you cannot find documentation of time left, or if it is illogical. We added the option to use EMS time because often the referring facility records are missing data. If the times seem incongruent, you …

You are correct in your thinking! Extrication is defined as any action that disentangles or frees from entrapment or delays in transport. Since the fire department rescued the patient from the building fire, this would qualify as yes for extrication. The primary intent of this element is to give a reason for delays in transport. …

We recommend using walk-in as the scene provider and recording the time of injury as the admission date/time. This allows for abstraction to really begin with the injury/fall and not with their initial admission at the referring facility.

There is no specific timeframe. While intent is to document if there is a delay, there does not need to be a delay to report extrication.

The PTOS Manual provides examples of common paralyzing drugs under the Paralyzing Drugs data element. Rocuronium is included within these examples. Under GCS qualifiers, I recommend Rocuronium be recorded as a paralyzing drug and Ketamine be recorded under sedation. Note that each of these agents has a slightly different duration of action (as you mention), …

It sounds like you have two separate encounters here. The first, I’m assuming, is nonPTOS as the patient most likely left AMA prior to meeting a portion of the inclusion criteria (i.e. LOS). The second encounter should be captured as a separate trauma record that will be PTOS. Information about the injury itself will remain …

You are to record the first assessment of each vital sign after the patient leaves the facility.   

If the x-ray is for the hip specifically, I recommend using the BQ0 code. If it is a diagnostic x-ray that is of the entire pelvis that happened to identify a hip injury, that is when I would use the BW01ZZZ code. If you would like to send over the documentation you have, we can …

You may enter 1, yes. It sounds like you have documentation from the non-acute care hospital. If this is the case, you will enter 2, no, for is this a transfer patient element. But you will then enter 1, yes, for documentation available from outside facility on the Referring Facility tab.

For PTOS, the scene is the scene of injury. Therefore, it would be the patient’s home.