Form Type | Variable | ID | Question | History |
|---|---|---|---|---|
Form 1 | Fracture1 | 3450 | Bone Fracture 1 | 1989-10-01 - Variable Added |
Form 1 | Fracture2 | 3451 | Bone Fracture 2 | 1989-10-01 - Variable Added |
Form 1 | Fracture3 | 3452 | Bone Fracture 3 | 1989-10-01 - Variable Added |
Form 1 | Fracture4 | 3453 | Bone Fracture 4 | 1989-10-01 - Variable Added |
Form 1 | Fracture5 | 3454 | Bone Fracture 5 | 1989-10-01 - Variable Added |
Form 1 | Fracture6 | 3455 | Bone Fracture 6 | 1989-10-01 - Variable Added |
Form 1 | Fracture7 | 3456 | Bone Fracture 7 | 1989-10-01 - Variable Added |
Form 1 | FractureS1 | 3457 | Fracture Side 1 | 1989-10-01 - Variable Added |
Form 1 | FractureS2 | 3458 | Fracture Side 2 | 1989-10-01 - Variable Added |
Form 1 | FractureS3 | 3459 | Fracture Side 3 | 1989-10-01 - Variable Added |
Form 1 | FractureS4 | 3460 | Fracture Side 4 | 1989-10-01 - Variable Added |
Form 1 | FractureS5 | 3461 | Fracture Side 5 | 1989-10-01 - Variable Added |
Form 1 | FractureS6 | 3462 | Fracture Side 6 | 1989-10-01 - Variable Added |
Form 1 | FractureS7 | 3463 | Fracture Side 7 | 1989-10-01 - Variable Added |
ASSOCIATED INJURIES - ARCHIVE
BONE FRACTURE - ARCHIVE
Definition
A break of a bone including open and closed fractures occurring at the same time as the brain injury. Each of the fractures are coded individually.
Form
[X] Form 1
[ ] Form 2
Source
- Abstraction (acute record)
Details
If fewer than seven fractures were reported, then code remaining fields with 88. Do not leave blanks.
Spinal fractures should be coded “8” - not applicable for laterality if vertebral body fracture only. If pedicle, lamina or transverse process fracture, use appropriate laterality code.
Hemotympanurn is considered equivalent to a basilar skull fracture even if there is no fracture detected on x-ray.
Metacarpal, carpal, wrist, metatarsals, scapula, and clavicle fractures should be coded as “77=other bones”
If there are no fractures, code all fracture fields and laterality fields with 1. If there are less than 7 fractures, code all remaining fracture fields and laterality fields which have no fractures with 8.
If there is any question regarding which code to use for a particular bone fracture, please consult your staff physiatrist. Do not code fractures which fall within the same code more than once.
*Code for facial fractures= 13 was added 4/19/99, previous to that time, facial fractures were coded 02 - calvarial or 77 - other. This data was not recoded.
Variables
Codes and Values
ID 3450
For Form: [Form 1]
For Variables: [Fracture1]
Code | Description |
|---|---|
1 | None at All |
2 | Calvarial ( Head, skull, excl. base of skull ) |
3 | Basilar ( Including hemotympanum ) |
4 | Maxillary ( Upper jaw ) |
5 | Mandibular ( Lower jaw ) |
6 | Ribs and/or Sternum ( Breastbone ) |
7 | Pelvis ( Hip ) |
8 | Humerus ( Upper arm ) |
9 | Radius and/or Ulna ( Forearm ) |
10 | Femur ( Thigh ) |
11 | Tibia and/or Fibula ( Lower leg ) |
12 | Spinal Column |
13 | Facial Fractures ( Includes: orbital, LeForte, nasal, zygomatic arch, sinus [ethmoid, frontal] ) |
77 | Other Bones |
88 | Not Applicable ( No further fractures were reported ) |
99 | Unknown |
ID 3451
For Form: [Form 1]
For Variables: [Fracture2]
Code | Description |
|---|---|
1 | None at All |
2 | Calvarial ( Head, skull, excl. base of skull ) |
3 | Basilar ( Including hemotympanum ) |
4 | Maxillary ( Upper jaw ) |
5 | Mandibular ( Lower jaw ) |
6 | Ribs and/or Sternum ( Breastbone ) |
7 | Pelvis ( Hip ) |
8 | Humerus ( Upper arm ) |
9 | Radius and/or Ulna ( Forearm ) |
10 | Femur ( Thigh ) |
11 | Tibia and/or Fibula ( Lower leg ) |
12 | Spinal Column |
13 | Facial Fractures ( Includes: orbital, LeForte, nasal, zygomatic arch, sinus [ethmoid, frontal] ) |
77 | Other Bones |
88 | Not Applicable ( No further fractures were reported ) |
99 | Unknown |
ID 3452
For Form: [Form 1]
For Variables: [Fracture3]
Code | Description |
|---|---|
1 | None at all |
2 | Calvarial ( Head, skull, excl. base of skull ) |
3 | Basilar ( Including hemotympanum ) |
4 | Maxillary ( Upper jaw ) |
5 | Mandibular ( Lower jaw ) |
6 | Ribs and/or Sternum ( Breastbone ) |
7 | Pelvis ( Hip ) |
8 | Humerus ( Upper arm ) |
9 | Radius and/or Ulna ( Forearm ) |
10 | Femur ( Thigh ) |
11 | Tibia and/or Fibula ( Lower leg ) |
12 | Spinal Column |
13 | Facial Fractures ( Includes: orbital, LeForte, nasal, zygomatic arch, sinus [ethmoid, frontal] ) |
77 | Other Bones |
88 | Not Applicable ( No further fractures were reported ) |
99 | Unknown |
ID 3453
For Form: [Form 1]
For Variables: [Fracture4]
Code | Description |
|---|---|
1 | None at all |
2 | Calvarial ( Head, skull, excl. base of skull ) |
3 | Basilar ( Including hemotympanum ) |
4 | Maxillary ( Upper jaw ) |
5 | Mandibular ( Lower jaw ) |
6 | Ribs and/or Sternum ( Breastbone ) |
7 | Pelvis ( Hip ) |
8 | Humerus ( Upper arm ) |
9 | Radius and/or Ulna ( Forearm ) |
10 | Femur ( Thigh ) |
11 | Tibia and/or Fibula ( Lower leg ) |
12 | Spinal Column |
13 | Facial Fractures ( Includes: orbital, LeForte, nasal, zygomatic arch, sinus [ethmoid, frontal] ) |
77 | Other Bones |
88 | Not Applicable ( No further fractures were reported ) |
99 | Unknown |
ID 3454
For Form: [Form 1]
For Variables: [Fracture5]
Code | Description |
|---|---|
1 | None at all |
2 | Calvarial ( Head, skull, excl. base of skull ) |
3 | Basilar ( Including hemotympanum ) |
4 | Maxillary ( Upper jaw ) |
5 | Mandibular ( Lower jaw ) |
6 | Ribs and/or Sternum ( Breastbone ) |
7 | Pelvis ( Hip ) |
8 | Humerus ( Upper arm ) |
9 | Radius and/or Ulna ( Forearm ) |
10 | Femur ( Thigh ) |
11 | Tibia and/or Fibula ( Lower leg ) |
12 | Spinal Column |
13 | Facial Fractures ( Includes: orbital, LeForte, nasal, zygomatic arch, sinus [ethmoid, frontal] ) |
77 | Other Bones |
88 | Not Applicable ( No further fractures were reported ) |
99 | Unknown |
ID 3455
For Form: [Form 1]
For Variables: [Fracture6]
Code | Description |
|---|---|
1 | None at all |
2 | Calvarial ( Head, skull, excl. base of skull ) |
3 | Basilar ( Including hemotympanum ) |
4 | Maxillary ( Upper jaw ) |
5 | Mandibular ( Lower jaw ) |
6 | Ribs and/or Sternum ( Breastbone ) |
7 | Pelvis ( Hip ) |
8 | Humerus ( Upper arm ) |
9 | Radius and/or Ulna ( Forearm ) |
10 | Femur ( Thigh ) |
11 | Tibia and/or Fibula ( Lower leg ) |
12 | Spinal Column |
13 | Facial Fractures ( Includes: orbital, LeForte, nasal, zygomatic arch, sinus [ethmoid, frontal] ) |
77 | Other Bones |
88 | Not Applicable ( No further fractures were reported ) |
99 | Unknown |
ID 3456
For Form: [Form 1]
For Variables: [Fracture7]
Code | Description |
|---|---|
1 | None at all |
2 | Calvarial ( Head, skull, excl. base of skull ) |
3 | Basilar ( Including hemotympanum ) |
4 | Maxillary ( Upper jaw ) |
5 | Mandibular ( Lower jaw ) |
6 | Ribs and/or Sternum ( Breastbone ) |
7 | Pelvis ( Hip ) |
8 | Humerus ( Upper arm ) |
9 | Radius and/or Ulna ( Forearm ) |
10 | Femur ( Thigh ) |
11 | Tibia and/or Fibula ( Lower leg ) |
12 | Spinal Column |
13 | Facial Fractures ( Includes: orbital, LeForte, nasal, zygomatic arch, sinus [ethmoid, frontal] ) |
77 | Other Bones |
88 | Not Applicable ( No further fractures were reported ) |
99 | Unknown |
ID 3457
For Form: [Form 1]
For Variables: [FractureS1]
Code | Description |
|---|---|
1 | Neither |
2 | Left |
3 | Right |
4 | Bilateral |
5 | Not Specified |
8 | Not Applicable |
9 | Unknown |
ID 3458
For Form: [Form 1]
For Variables: [FractureS2]
Code | Description |
|---|---|
1 | Neither |
2 | Left |
3 | Right |
4 | Bilateral |
5 | Not Specified |
8 | Not Applicable |
9 | Unknown |
ID 3459
For Form: [Form 1]
For Variables: [FractureS3]
Code | Description |
|---|---|
1 | Neither |
2 | Left |
3 | Right |
4 | Bilateral |
5 | Not Specified |
8 | Not Applicable |
9 | Unknown |
ID 3460
For Form: [Form 1]
For Variables: [FractureS4]
Code | Description |
|---|---|
1 | Neither |
2 | Left |
3 | Right |
4 | Bilateral |
5 | Not Specified |
8 | Not Applicable |
9 | Unknown |
ID 3461
For Form: [Form 1]
For Variables: [FractureS5]
Code | Description |
|---|---|
1 | Neither |
2 | Left |
3 | Right |
4 | Bilateral |
5 | Not Specified |
8 | Not Applicable |
9 | Unknown |
ID 3462
For Form: [Form 1]
For Variables: [FractureS6]
Code | Description |
|---|---|
1 | Neither |
2 | Left |
3 | Right |
4 | Bilateral |
5 | Not Specified |
8 | Not Applicable |
9 | Unknown |
ID 3463
For Form: [Form 1]
For Variables: [FractureS7]
Code | Description |
|---|---|
1 | Neither |
2 | Left |
3 | Right |
4 | Bilateral |
5 | Not Specified |
8 | Not Applicable |
9 | Unknown |
History
No history found for the Domain.
CRANIAL NERVE - ARCHIVE
Definition
Injury to a cranial nerve occurring at the same time as the brain injury assessed at any time during initial acute care or rehabilitation hospitalization. These include injuries to the cranial nerve nuclei and/or peripheral cranial nerves, resulting in a lower motor neuron lesion, with the following exceptions: 1) Cranial nerve I (olfaction) and II (vision) have direct central projections; 2) Cranial nerve VII (facial movements) can be damaged peripherally at the nerve nucleus of nerve, or facial movement can be paralyzed centrally as a result of cortical or subcortical injury. When Cranial nerve VII is damaged centrally, half the face is paralyzed but the half forehead is spared (i.e., still moves); when it is damaged peripherally, half the forehead is paralyzed along with half of the lower face.
Form
[X] Form 1
[ ] Form 2
Source
- Abstraction - Acute and Rehabilitation Record
- Pocket Smell Test used to assess Cranial Nerve I
Details
Cranial Nerve I: Enter #correct on Pocket Smell Test.
The Pocket Smell test should be used to test cranial nerve I, this test can be administered as part of the neuropsychological battery or during physical examination at anytime during initial acute care or rehab-ilitation hospitalization. The Pocket Smell test can be ordered from Sensonics, Inc. 609 547-7702 *(order from the internet at: http://www.smelltest.com/index.htm). The Pocket Smell Test 75–3 panel pocket smell tests. The changes for CN I and CN VII go into effect as of admissions to acute care beginning 7/1/99. The old data for Cranial Nerve I will be re-coded to unknown. The old data for Cranial Nerve VII will be coded under Cranial Nerve VII (unknown if central or peripheral).
Characteristics
Coding scheme revised and laterality dropped 9/13/1994.
Pocket Smell Test added 7/1/1999
Variables
Form Type | Variable | ID | Question | History |
|---|---|---|---|---|
Form 1 | Crainial10 | 3384 | Cranial Nerve X | 1989-10-01 - Variable Added |
Form 1 | Crainial11 | 3385 | Cranial Nerve XI | 1989-10-01 - Variable Added |
Form 1 | Crainial12 | 3386 | Cranial Nerve XII | 1989-10-01 - Variable Added |
Form 1 | Crainial2 | 3387 | Cranial Nerve II | 1989-10-01 - Variable Added |
Form 1 | Crainial3 | 3388 | Cranial Nerve III | 1989-10-01 - Variable Added |
Form 1 | Crainial4 | 3389 | Cranial Nerve IV | 1989-10-01 - Variable Added |
Form 1 | Crainial5 | 3390 | Cranial Nerve V | 1989-10-01 - Variable Added |
Form 1 | Crainial6 | 3391 | Cranial Nerve VI | 1989-10-01 - Variable Added |
Form 1 | Crainial7 | 3392 | Cranial Nerve VII | 1989-10-01 - Variable Added |
Form 1 | Crainial7Cent | 3393 | Central CN VII | 1989-10-01 - Variable Added |
Form 1 | Crainial7Perip | 3394 | Peripheral CN VII | 1989-10-01 - Variable Added |
Form 1 | Crainial8 | 3395 | Cranial Nerve VII | 1989-10-01 - Variable Added |
Form 1 | Crainial9 | 3396 | Cranial Nerve IX | 1989-10-01 - Variable Added |
Form 1 | Cranial1 | 3397 | Cranial Nerve I -Pocket Smell Test | 1989-10-01 - Variable Added |
Codes and Values
ID 3384
For Form: [Form 1]
For Variables: [Crainial10]
Code | Description |
|---|---|
0 | Variable Did Not Exist |
1 | No Injury To Cranial Nerve |
2 | Yes, Injury To Cranial Nerve |
7 | Not Testable |
9 | Unknown |
ID 3385
For Form: [Form 1]
For Variables: [Crainial11]
Code | Description |
|---|---|
0 | Variable Did Not Exist |
1 | No Injury To Cranial Nerve |
2 | Yes, Injury To Cranial Nerve |
7 | Not Testable |
9 | Unknown |
ID 3386
For Form: [Form 1]
For Variables: [Crainial12]
Code | Description |
|---|---|
0 | Variable Did Not Exist |
1 | No Injury To Cranial Nerve |
2 | Yes, Injury To Cranial Nerve |
7 | Not Testable |
9 | Unknown |
ID 3387
For Form: [Form 1]
For Variables: [Crainial2]
Code | Description |
|---|---|
0 | Variable Did Not Exist |
1 | No Injury To Cranial Nerve |
2 | Yes, Injury To Cranial Nerve |
7 | Not Testable |
9 | Unknown |
ID 3388
For Form: [Form 1]
For Variables: [Crainial3]
Code | Description |
|---|---|
0 | Variable Did Not Exist |
1 | No Injury To Cranial Nerve |
2 | Yes, Injury To Cranial Nerve |
7 | Not Testable |
9 | Unknown |
ID 3389
For Form: [Form 1]
For Variables: [Crainial4]
Code | Description |
|---|---|
0 | Variable Did Not Exist |
1 | No Injury To Cranial Nerve |
2 | Yes, Injury To Cranial Nerve |
7 | Not Testable |
9 | Unknown |
ID 3390
For Form: [Form 1]
For Variables: [Crainial5]
Code | Description |
|---|---|
0 | Variable Did Not Exist |
1 | No Injury To Cranial Nerve |
2 | Yes, Injury To Cranial Nerve |
7 | Not Testable |
9 | Unknown |
ID 3391
For Form: [Form 1]
For Variables: [Crainial6]
Code | Description |
|---|---|
0 | Variable Did Not Exist |
1 | No Injury To Cranial Nerve |
2 | Yes, Injury To Cranial Nerve |
7 | Not Testable |
9 | Unknown |
ID 3392
For Form: [Form 1]
For Variables: [Crainial7]
Code | Description |
|---|---|
0 | Variable Did Not Exist |
1 | No Injury To Cranial Nerve |
2 | Yes, Injury To Cranial Nerve |
7 | Not Testable |
9 | Unknown |
ID 3393
For Form: [Form 1]
For Variables: [Crainial7Cent]
Code | Description |
|---|---|
0 | Variable Did Not Exist |
1 | No Injury To Cranial Nerve |
2 | Yes, Injury To Cranial Nerve |
7 | Not Testable |
9 | Unknown |
ID 3394
For Form: [Form 1]
For Variables: [Crainial7Perip]
Code | Description |
|---|---|
0 | Variable Did Not Exist |
1 | No Injury To Cranial Nerve |
2 | Yes, Injury To Cranial Nerve |
7 | Not Testable |
9 | Unknown |
ID 3395
For Form: [Form 1]
For Variables: [Crainial8]
Code | Description |
|---|---|
0 | Variable Did Not Exist |
1 | No Injury To Cranial Nerve |
2 | Yes, Injury To Cranial Nerve |
7 | Not Testable |
9 | Unknown |
ID 3396
For Form: [Form 1]
For Variables: [Crainial9]
Code | Description |
|---|---|
0 | Variable Did Not Exist |
1 | No Injury To Cranial Nerve |
2 | Yes, Injury To Cranial Nerve |
7 | Not Testable |
9 | Unknown |
ID 3397
For Form: [Form 1]
For Variables: [Cranial1]
Code | Description |
|---|---|
0 | None |
1 | One |
2 | Two |
3 | Three |
7 | Not Testable |
8 | Variable Did Not Exist |
9 | Unknown |
History
No history found for the Domain.
INTRA-ABDOMINAL - ARCHIVE
Definition
Trauma to the abdominal structures (e.g. liver, gall bladder, kidney, ureters, spleen, pancreas, uterus, ovaries, stomach, intestines, peritoneum and retroperitoneum).
Form
[X] Form 1
[ ] Form 2
Source
- Acute Medical Record Abstraction
Details
Only intra-abdominal injuries that occur at the same time as the brain injury should be reported.
Include injuries to the peritoneum and retroperitoneum.
Variables
Form Type | Variable | ID | Question | History |
|---|---|---|---|---|
Form 1 | Abdom | 3333 | Intra-abdominal Injury | 1989-10-01 - Variable Added |
Codes and Values
ID 3333
For Form: [Form 1]
For Variables: [Abdom]
Code | Description |
|---|---|
2 | Yes |
9 | Unknown |
History
No history found for the Domain.
PNEUMOTHORAX - ARCHIVE
Definition
Traumatic pneumothorax and/or hemothorax: The occurrence of air and/or fluid within the pleural space that can be demonstrated radiographically and requiring chest tube intervention.
Form
[X] Form 1
[ ] Form 2
Source
- Acute Medical Record Abstraction
Details
Only instances which are present at the time of admission to the Model System ED should be reported.
Variables
Form Type | Variable | ID | Question | History |
|---|---|---|---|---|
Form 1 | Pneumothorax | 3501 | Traumatic Pneumothorax and/or Hemothorax | 1989-10-01 - Variable Added |
Codes and Values
ID 3501
For Form: [Form 1]
For Variables: [Pneumothorax]
Code | Description |
|---|---|
1 | No |
2 | Yes |
9 | Unknown |
History
No history found for the Domain.