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October 29, 2021

I’m looking for direction regarding a case that was seen post MVA and left AMA prior to imaging results. He was called back to the ED and transferred out for care. He initially was brought in direct from scene of MVA by EMS. His second visit, where he was transferred out to higher level of care, he was brought in by EMS from home. How do I address the EMS data?

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 the same; however, arrival information and care information should only be recorded in Collector based on the second encounter. For PTOS, you will enter the scene information based on the EMS provider who took him from his home to your center. I would encourage you to enter some information regarding the first encounter with this patient in your notes/memo sections of Collector. If you complete information in the yellow memo section, please remember to exclude any patient or provider identifying information as that information is sent to us at the central site.

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