Form Type | Variable | ID | Question | History |
|---|---|---|---|---|
Form 1 | FollowComm | 499 | Date able to follow commands: | 1989-10-01 - Variable Added |
SEVERITY
Definition
Injury severity measures
Characteristics
CONSSTAT (Consciousness Status) and DTLOC (Date of First LOC) were collected from 1/01/1990 to 4/01/1999. NO DATA AVAILABLE. Definition = Beginning= first loss of consciousness. End= the emergence from unconsciousness; specifically, the demonstration of environmental awareness as indicated by a Glasgow Coma Score (Motor Component) of 5 or greater. A patient with severe motor or sensory impairment (i.e. spinal cord injury, locked in syndrome) must demonstrate some cord ability to follow eye commands such as close your eyes, look to the right or left, blink your eyes.
DTGCS was collected from 1/01/1990 to 4/01/1999. NO DATA AVAILABLE. Definition =Enter the date the patient’s GCS motor score was 5 or greater. NOTE: A patient with severe motor or sensory impairment (i.e. spinal cord injury, locked in syndrome) must demonstrate some ability to follow eye commands such as close your eyes, look to the right or left, blink your eyes. If patient’s GCS motor score <5 at the time of TBI system discharge but was >=5 following that date, change the date the GCS motor score >=5 from 8’s to the date this occurred.
COMMAND FOLLOWING
Definition
Date that the individual with brain injury is able to follow simple motor commands. The individual has the ability to follow simple motor commands if:
- follows simple motor commands accurately at least two out of two times within a 24-hour period, or
- GCS motor component = 6 (follows simple motor commands), two out of two times within a 24-hour period.
The purpose of this variable is to establish the duration of unconsciousness.
Form
[X] Form 1
[ ] Form 2
Source
Form 1 - Abstraction (acute or rehab record)
Details
A patient with severe motor or sensory impairment (i.e. spinal cord injury, locked in syndrome) must demonstrate some ability to follow eye commands such as close your eyes, look to the right or left, blink eyes.
If patient is able to follow commands, then following surgery he/she can not follow commands for a period of time, use the first date the patient was able to follow commands.
If the two assessments of ability to follow simple motor commands within a 24-hour period fall across two dates, use the second date.
If patient was always able to follow simple motor commands, code date of admission to emergency room.
Notes such as ‘’following commands at times’’ or ‘’follows some commands’’ may be used, as long as the ability to follow commands is documented 2 times consecutively.
Notes of “inconsistently following commands” should be counted as following.
Other scenarios that indicate following commands include “ability to answer questions appropriately” or “2 consecutive GSC total scores of 15”.
Scenarios that indicate NOT following commands include “localizing”, “flexing”, “withdraws from pain” or “posturing”.
In unusual cases where two or more motor scores of 6 occur within a very short time frame of each other but have motor scores preceding and following that are below 6, data collectors should consult with their Project Director or Medical Director.
If patient was always able to follow simple motor commands, code date of admission to emergency room.
Variables
Codes and Values
ID | Code | Description |
|---|---|---|
499 | 08/08/8888 | Patient Never Able to Follow Simple Motor Commands |
499 | 09/09/9999 | Unknown |
History
Date | Description |
|---|---|
1994-09-13 | DELETED NOTE : reference of this variable being a precondition to collect the physical exam data. |
1999-10-01 | Added NOTE : regarding if patient is able to follow commands, declines, then can again follow commands at a later date. |
1999-10-01 | Added NOTE : regarding if two assessments of following commands falls across two dates. |
2003-01-01 | Deleted CODE : 08/08/8888 - NA. |
2003-01-01 | Added instruction to code as date of admission to ER if patient was never unable to follow commands. |
2003-10-01 | Added NOTE : that the purpose of this variable is to establish the date of emergence from coma. |
2010-10-01 | Added NOTE : regarding ambiguous notes such as ''follows some commands''. |
2013-07-01 | Deleted NOTE : The purpose of this variable is to establish the date of emergence from coma |
2013-07-01 | Added NOTE: The purpose of this variable is to establish the duration of unconsciousness |
2016-07-01 | Added NOTE: In unusual cases where two or more motor scores of 6 occur within a very short time frame of each other but have motor scores preceding and following that are below 6, data collectors should consult with their Project Director or Medical Director. |
2020-03-26 | Added NOTE : Notes of "inconsistently following commands" should be counted as following. |
2022-12-15 | Removed NOTE : "...shows equal strength bilaterally" from other scenarios that indicate command following. |
COMMAND FOLLOWING - CALCULATED
Variables
Form Type | Variable | ID | Question | History |
|---|---|---|---|---|
Form 1 | TFCDays | 559 | Days From Injury to Follow Commands | 1989-10-01 - Variable Added |
Codes and Values
ID | Code | Description |
|---|---|---|
559 | 7777 | Patient Never Able to Follow Simple Motor Commands |
559 | 9999 | Unknown |
History
No history found for the Domain.
GCS (GLASGOW COMA SCALE)
Definition
Glasgow Coma Scale scores on admission to emergency department.
Form
[X] Form 1
[ ] Form 2
Source
Form 1 - Abstraction (acute record)
Details
If patient was admitted to a model systems acute facility within the first 24 hours of injury, use model systems ER data. However, if the patient was not admitted to a model systems acute facility within the first 24 hours of injury, use the first ER to obtain GCS data regardless of whether it was a model systems ER or not.
If only 1 GCS is recorded, use that score for an assessment.
If the patient is chemically paralyzed with neuromuscular blocking agents or barbiturates, or is sedated with anesthetics, code the GCS as ‘Chemically Paralyzed or Sedated’ even if GCS scores are present in the record. The paralysis or sedation must be induced by medical personnel, and not by the patient.
If however, a GCS score of 15 is present in the record, and there is evidence that the patient was given sedatives, do not code as sedated, and use the Verbal score and Total score provided in the record.
Applicable medications commonly used in emergency care for sedation include…
Neuromuscular blocking agents: atracurium (TRACRIUM), pancuronium (PAVULON), rocuronium (ZEMURON), succinylcholine (ANECTINE, QUELICIN), vecuronium (NORCURON) and ketamine (KETALAR).
Barbiturates: pentobarbital (NEMBUTAL), and sodium thiopental (SODIUM PENTOTHAL or THIOPENTAL).
Anesthetics: fentanyl (ABSTRAL, ACTIQ, DUROGESIC, FENTORA, IONSYS, LAZANDA, ONSOLIS, SUBLIMAZE, SUBSYS), lorazepam (ATIVAN), midazolam (VERSED), and propofol (DIPRIVAN).
If chemical paralysis or sedation at time of arrival is unclear, data collectors should seek the advice of their project director or physician at their hospital.
If patient is intubated at the time of assessment, record the verbal score as 8 and the total score as 88. For the purposes of analysis, these cases will not be included unless specified for recoding during analysis.
If patient is intubated and in chemically-induced coma or paralysis, code 8 for verbal response and 7’s for eye opening, motor response and 77 for total GCS.
If patient is only nasally intubated, the patient can provide a verbal GCS score (do not code as intubated).
If patient is only bagged, the patient can provide a verbal GCS score (do not code as intubated). Medical records may show this as “BVM” (bag-valve-mask ventilated).
If patient is intubated using RSI (rapid sequence intubation), code as intubated and sedated.
Links
Reference
Teasdale G, Jennett B (1976) Assessment and Prognosis of Coma After Head Injury, Acta Neurochir 34, 45-55.
Characteristics
In the days that 3 GCSs were collected (highest, lowest, admit), there was the option of using 1 GCS for the other 2 GCSs if they were missing. A cursory check suggests that this was not done consistently.
Variables
Form Type | Variable | ID | Question | History |
|---|---|---|---|---|
Form 1 | GCSEye | 502 | GCS Eye opening: | 1989-10-01 - Variable Added |
Form 1 | GCSMot | 503 | GCS Motor: | 1989-10-01 - Variable Added |
Form 1 | GCSTot | 504 | GCS Total: | 1989-10-01 - Variable Added |
Form 1 | GCSVer | 505 | GCS Verbal: | 1989-10-01 - Variable Added |
Codes and Values
ID | Code | Description |
|---|---|---|
502 | 1 | None |
502 | 2 | To Pain |
502 | 3 | To Voice |
502 | 4 | Spontaneous |
502 | 7 | Chemically Paralyzed or Sedated |
502 | 99 | Unknown |
503 | 1 | None |
503 | 2 | Extension to Pain |
503 | 3 | Flexion to Pain |
503 | 4 | Withdraws from Pain |
503 | 5 | Localizes Pain |
503 | 6 | Obeys Commands |
503 | 7 | Chemically Paralyzed or Sedated |
503 | 99 | Unknown |
504 | 77 | Chemically Paralyzed or Sedated |
504 | 88 | Intubated |
504 | 999 | Unknown |
505 | 1 | None |
505 | 2 | Incomprehensible Sounds |
505 | 3 | Inappropriate Speech |
505 | 4 | Confused |
505 | 5 | Oriented |
505 | 7 | Chemically Paralyzed or Sedated |
505 | 8 | Intubated |
505 | 99 | Unknown |
History
Date | Description |
|---|---|
1994-02-01 | Added NOTE : to clarify which GCS scores to use. |
1995-01-01 | Deleted CODES : 88 and 8 - Not applicable codes. |
1995-07-01 | Added CODE : 7 for individual items and 77 for total = "chemically induced coma or paralysis". |
1995-07-01 | Added CODE : T=intubated for verbal item and TT=intubated for total. |
1995-07-01 | Deleted VARIABLE: eye swelling and intubation items. |
1996-04-01 | Changed CODES : for patient intubated from “T” and “TT” to “8” and “88”. |
1999-01-01 | Added NOTE : regarding chemical paralysis. |
1999-04-01 | Added NOTE : that GCS at ED is Model System ED. |
2004-04-01 | Changed CODE : added "sedated" to reasons for coding "7". |
2004-04-01 | Changed NOTE : added list of sedatives. |
2009-10-01 | Changed DEFINITION : Data from non model systems emergency departments may be used if not admitted to model systems facility within the first 24 hours. Change corresponds with expansion of inclusion criteria to 72 hours. |
2011-04-01 | Added NOTE : If patient is nasally intubated they can provide a verbal GCS score. |
2020-03-25 | Added NOTE : If however, a GCS score of 15 is present in the record, and there is evidence that the patient was given sedatives, do not code as sedated, and use the Verbal score and Total score provided in the record. |
2021-11-23 | Updated NOTE: If patient is only nasally intubated, the patient can provide a verbal GCS score (do not code as intubated). If patient is only bagged, the patient can provide a verbal GCS score (do not code as intubated). Medical records may show this as "BVM" (bag-valve-mask ventilated). |
2022-04-19 | Added to NOTE : "Ketamine (KETALAR)" as a |
GCS (GLASGOW COMA SCALE) - CALCULATED
Variables
Form Type | Variable | ID | Question | History |
|---|---|---|---|---|
Form 1 | GCS | 500 | GCS Total on Admission | 1989-10-01 - Variable Added |
Form 1 | GCSCat | 501 | GCS Category | 1989-10-01 - Variable Added |
Codes and Values
ID | Code | Description |
|---|---|---|
500 | 77 | Patient Chemically Paralyzed or in Chemically-Induced Coma for Treatment Purposes: Sedated |
500 | 88 | Intubated |
500 | 999 | Unknown Total GCS Score |
501 | 1 | Severe |
501 | 2 | Moderate |
501 | 3 | Mild |
501 | 77 | Intubated |
501 | 999 | Missing |
History
No history found for the Domain.
PTA
Definition
Date of emergence from Post-traumatic Amnesia (PTA).
Where possible, PTA emergence should be measured (tracked) prospectively by direct testing. With prospective tracking, emergence from PTA is defined as:
- two consecutive GOAT scores of 76 or greater with no more than 2 full calendar days between assessments (Assessment 1 = Friday, Assessment 2 = Monday, two full days = Saturday, Sunday)
- two consecutive scores of 11 or greater on the Revised GOAT with no more than 2 full calendar days between assessments (Assessment 1 = Friday, Assessment 2 = Monday, two full days = Saturday, Sunday)
- two consecutive scores of 25 or greater on the Orientation-Log with no more than 2 full calendar days between assessments (Assessment 1 = Friday, Assessment 2 = Monday, two full days = Saturday, Sunday)
- two consecutive scores of 8 or greater on the Non-Verbal version of the Orientation-Log with no more than 2 full calendar days between assessments (Assessment 1 = Friday, Assessment 2 = Monday, two full days = Saturday, Sunday), or
- in the judgment of a qualified clinician (i.e., speech-language pathologist, physician, neuropsychologist), the person has cleared PTA but administration of an orientation test is not possible due to language functioning.
The day of clearance of PTA is the first day the person gets the first of 2 consecutive scores of 76 or greater on the GOAT, the first of 2 consecutive scores of 11 or greater on the Revised GOAT, the first of 2 consecutive scores of 25 or greater on the Orientation-Log, or the first of 2 consecutive scores of 8 or greater on the Non-Verbal version of the Orientation-Log.
If within a 7-day period, there are multiple scores exceeding the PTA cut-off, but the first two are separated by more than two full calendar days (e.g. Assessment 1 = Friday, Assessment 2 = Tuesday; this would be 3 full calendar days apart), then it is acceptable to use the midpoint between the first and second dates the PTA assessment was administered.
It is the choice of the Project Director as to whether to use the GOAT, Revised GOAT (Bode, Heinemann, & Semik, 2000 – see SOURCES) or the Orientation-Log (Jackson, Novack, & Dowler, 1998; Novack, Dowler, Bush, Glen, & Schneider, 2000 – see SOURCES) to establish the duration of PTA. Alternating use of the scales in an individual patient is not acceptable, however. Preferably, copies of the test protocols documenting PTA tracking should be kept in the research record. If the PTA data is elsewhere (e.g., in the rehabilitation chart), the location should be noted in the research record.
The Non-Verbal version of the Orientation-Log is the preferred assessment of orientation for persons with traumatically induced expressive language disorder with significant difficulty generating comprehensible verbal output. Common causes for this problem include expressive aphasia and severe dysarthria accompanied by an inability to write responses. Non-verbal responses are scored according to the following criteria: 1 = correct upon multiple choice / 0 = incorrect or no response. This scoring adjustment is intended to be used only for non-verbal individuals with significant difficulty generating comprehensible verbal or written output. Careful clinical judgment will be required in each case to determine that the person’s expressive problems are clearly due to neurological disorder, and the person is unable to respond in writing.
Determining Date of PTA Emergence During Acute Care
For those patients who are already oriented at rehabilitation admission (as defined by the first two GOAT scores after rehabilitation admission >75), prospective tracking of the date of emergence from PTA is not possible, because the date falls within the acute care stay. In these cases, PTA emergence can be determined via chart review of the acute care records only. (NOTE: Rehabilitation hospital charts may NOT be used for this purpose). The following procedure can be used to determine the length of PTA based on acute care hospital records. This procedure should be followed only for those patients who are oriented at rehabilitation admission.
Obtain all available physician, nursing and therapy notes from the acute hospitalization. In most hospital medical records, physician, nursing and therapy notes are filed in different sections. You may have to specifically request therapy and nursing notes, if you routinely only receive the physician progress notes.
Review all notes to determine the first DATE on which all notes referencing orientation indicate that the patient is fully oriented, oriented X 3 (or 4), or GCS Verbal Score = 5 (oriented). This is Orientation Day 1.
Review notes from the next calendar day to determine if all relevant notes again indicate that the patient is fully oriented.
If yes, the second day is Orientation Day 2, and Orientation Day 1 is the resolution date of PTA. If there are missing notes or no comments about orientation on the second day, keep looking for the second day that the notes consistently document full orientation. As long as Orientation Day 2 is no more than 2 full calendar days from Orientation Day 1, and if no notes from intervening days indicate less than full orientation, record Orientation Day 1 as the resolution date of PTA.
If any note from calendar days intervening between Orientation Days 1 and 2 indicate less than full orientation, use Day 2 as the new starting point (i.e., new Day 1) and repeat procedure from Step 3 above.
If there is no Orientation Day 2 (i.e., if the patient is never fully oriented on more than one day; or if more than 2 full calendar days elapse after Orientation Day 1 with no further notation about orientation), code date of PTA resolution as unknown. An exception would be if on the day before or the day of transfer to rehabilitation, the patient is specifically noted not to be oriented. If the patient then produces GOATs >75 on the first two examinations after rehabilitation admission, code the date of PTA resolution in the usual manner.
Form
[X] Form 1
[ ] Form 2
Source
Form 1 - Abstraction (acute record only) or measured by direct O-Log or GOAT testing (rehab record)
Details
Administer the test every 1 to 3 calendar days until patient emerges from PTA.
There is no code for “unknown” for method of PTA determination because this should never be unknowable. Please contact the TBINDC if you are in a situation in which this variable is truly unknown (and unknowable).
Code date of admission to ER if person was never in PTA.
If PTA lasts less than 24 hours, code day 2 as the date of emergence from PTA, since this would be the first day that they were fully oriented.
If participant was not out of PTA at Rehab discharge score is coded as “888. Person Still in PTA at time of Rehab Discharge”.
If a person was never in PTA the days = 0.
For cases who do not emerge from PTA by rehab discharge, code the method used to decide if the patient is still in PTA.
The same instrument must be used for all scores to capture the date emerged from PTA during rehabilitation. GOAT and O-Log scores may not be mixed and matched.
Record review can not be used to determine Date Emerged from PTA during rehab. If PTA was not tracked with GOAT or O-Log during rehab and patient did not emerge during the acute stay, Date Emerged from PTA should be coded as “09/09/9999 (Unknown)”, and Method of Determination should be coded as “88. (N/A PTA Not Tracked)”.
Patients who don’t have any documented GOAT or O-Log scores possibly due to other cognitive deficits (e.g. “confused due to dementia’‘) and formal testing may not have been possible should be’‘09/09/999 - Unknown’’ rather than ‘’08/08/8888 - Never Emerged.’’ The method of PTA determination should be coded as ‘88. PTA has not been tracked.’. Record review cannot be used to determine emergence from PTA during rehab.
If an acute record states “patient is A&O x3 with choices”, and the patient has aphasia or some other expressive language disorder, then testing with choices would be appropriate to asses orientation and would count as being oriented.
Computer calculates duration of post-traumatic amnesia by subtracting the date of injury from this date.
Duration of PTA is calculated only for those cases which emerge from PTA prior to discharge from inpatient rehabilitation.
Duration of PTA is not to be calculated from date of emergence from coma [FLLW], per decision of the neuropsychology databusters group.
Two consecutive GCS Verbal scores of “5-Oriented” may be used to determine length of PTA when there is no other source of documentation using acute chart review.
For cases who never had PTA, code “Method of PTA Determination” as “1-Acute Chart Review”.
Links
PTA - Introduction to O-Log (COMBI)
PTA - O-Log frequently asked questions (COMBI)
PTA - O-Log Syllabus (COMBI)
PTA - O-Log Rating Form (COMBI
PTA - O-Log Properties (COMBI)
PTA - O-Log References (COMBI)
PTA - Bode RK, Heinemann, AW, Semik P. for v144a
PTA - Jackson WT, Novack TA, Dowler RN for v144a
PTA - Novack TA, Dowler RN, Bush BA, Glen T, Schneider JJ. for v144a
PTA - Levin, HS, O’Donnell, VM, & Grossman, RG for v144a
Reference
GOAT: Levin, HS, O’Donnell, VM, & Grossman, RG. (1979). The Galveston Orientation and Amnesia Test: A practical scale to assess cognition after head injury. Journal of Nervous and Mental Diseases, 167, 675-684. See External Links
Revised GOAT: Bode RK, Heinemann AW, Semik P. Measurement properties of the Galveston Orientation and Amnesia Test (GOAT) and improvement patterns during inpatient rehabilitation. J Head Trauma Rehabil. 2000 Feb;15(1):637-55. See External Links
Orientation-Log (and Non-Verbal version of the Orientation-Log): Jackson WT, Novack TA, Dowler RN. Effective serial measurement of cognitive orientation in rehabilitation: the Orientation Log. Arch Phys Med Rehabil. 1998 Jun;79(6):718-20. Link to PubMed: See External Links
Novack, TA, Dowler, RN, Bush, BA, Glen, T, Schneider, JJ. Validity of the Orientation Log, Relative to the Galveston Orientation and Amnesia Test. J Head Trauma Rehabil, 2000, 15(3), 957-961. See External Links
Characteristics
A few participants have a very long time in PTA. These have been checked and found to be correct.
A modified GOAT can be used to assist with this decision. The examiner presents three alternatives, in written form and orally, including the correct choice for each question. The patient is to indicate a choice in some manner, such as nodding or pointing. This procedure can be used for all questions except numbers 4 and 5. The three response alternatives for each question should be arranged vertically in large print on an index card. Error points are assigned and subtracted from 80 (the maximum score with items 4 and 5 removed). A score of 61 or higher is reflective of orientation. PTA is considered resolved when a score of 61 or greater is achieved on two consecutive occasions with no more than 2 full calendar days between assessments (Assessment 1 = Friday, Assessment 2 = Monday, two full days = Saturday, Sunday). Scores from the modified GOAT are for determination of PTA duration only.
Variables
Form Type | Variable | ID | Question | History |
|---|---|---|---|---|
Form 1 | PTADate | 538 | Date emerged from PTA: | 1989-10-01 - Variable Added |
Form 1 | PTAMethod | 540 | Method of PTA determination: | 1989-10-01 - Variable Added |
Codes and Values
ID | Code | Description |
|---|---|---|
538 | 08/08/8888 | Not Applicable: Still in PTA at discharge |
538 | 09/09/9999 | Unknown |
540 | 1 | Acute Chart Review |
540 | 2 | GOAT |
540 | 3 | GOAT-R |
540 | 4 | O-Log |
540 | 5 | Clinical judgement: GOAT/O-Log not possible due to language functioning |
540 | 6 | Non-Verbal Version of the O-Log |
540 | 66 | Variable Did Not Exist |
540 | 88 | Not Applicable: PTA has not been tracked |
History
Date | Description |
|---|---|
1994-09-13 | Added NOTE : regarding use of modified GOAT. |
1995-07-01 | Added NOTE : regarding calculation of duration of PTA. |
1999-10-01 | Added NOTE : to clarify which date to use. |
2000-07-01 | Added NOTE : PTA determination based on Chart Review. |
2001-10-01 | Added NOTE : that date of emergence from PTA is the date of the first of 2 consecutive scores greater than 75. |
2002-01-01 | Added DEFINITION : the Revised GOAT, Orientation-Log, and modified GOAT. |
2003-01-01 | Deleted CODE : “07/07/7777 - Never had amnesia”. |
2003-01-01 | Added NOTE : that if person never had PTA, code date of admission to ER. |
2004-01-01 | Added NOTE : that NP databusters confirmed current procedure for calculation (approx 9/02). |
2004-04-01 | Changed DEFINITION : removed reference to the neuropsychological battery. |
2006-01-01 | Added NOTE : clocks, calendars are okay for tester to use. |
2006-01-01 | Added NOTE : about determining date by chart review if person not consented (and if not assessed clinically). |
2006-01-01 | Removed NOTE : that the Modified GOAT is to be used only for determining PTA. |
2008-04-01 | ADDED Code: '5' clinical judgement. |
2009-10-01 | Changed DEFINITION : changed wording from "within a period of 24 to 72 hours" to "within a period of 1 calendar day to 3 calendar days". |
2010-10-01 | Added DEFINITION : details for new assessment method - Non-Verbal version of the Orientation-Log. |
2010-10-01 | ADDED Code: '6' None Verbal Version of the O-LOG. |
2011-01-06 | Added NOTE : how to code participants who don't have any documented GOAT or OLOG scores possibly due to other cognitive deficits (e.g. "confused due to dementia'') and formal testing may not have been possible. |
2013-01-01 | Added DEFINITION : that GCS Verbal Scores of '5 = Oriented' may be used when determining length of PTA by chart review. |
2013-06-05 | Added NOTE : how to code if note reads "patient is A&O x3 with choices". |
2015-08-01 | Added NOTE : If PTA lasts less than 24 hours, code day 2 as the date of emergence from PTA, since this would be the first day that they were fully oriented. |
2015-08-01 | Added NOTE : to not use record review to determine PTA during rehab. |
2016-01-01 | Added NOTE : The same instrument must be used for all scores to capture the date emerged from PTA. GOAT and O-Log scores may not be mixed and matched. |
2017-01-15 | Changed DEFINITION : clarified 'within a period of 1 calendar day to 3 calendar days' with 'with no more than 2 full calendar days between assessments (Assessment 1 = Friday, Assessment 2=Monday, two full days=Saturday, Sunday)'. |
2025-07-01 | Note Added to Definition - "If within a 7-day period, there are multiple scores exceeding the PTA cut-off, but the first two are separated by more than two full calendar days (e.g. Assessment 1 = Friday, Assessment 2 = Tuesday; this would be 3 full calendar days apart), then it is acceptable to use the midpoint between the first and second dates the PTA assessment was administered. " |
PTA - CALCULATED
Variables
Form Type | Variable | ID | Question | History |
|---|---|---|---|---|
Form 1 | PTADays | 539 | Days From Injury to Date Out of PTA | 1989-10-01 - Variable Added |
Codes and Values
ID | Code | Description |
|---|---|---|
539 | 8888 | Person Still in PTA at time of Rehab Discharge |
539 | 9999 | Unknown |
History
No history found for the Domain.
RTS
Definition
Revised Trauma Score Systolic Blood Pressure and Respiratory Rate at admission to emergency department.
If patient was admitted to a model systems acute facility within the first 24 hours of injury, use model systems ER data. However, if the patient was not admitted to a model systems acute facility within the first 24 hours of injury, use the first ER to obtain RTS data regardless of whether it was a model systems ER or not.
Form
[X] Form 1
[ ] Form 2
Source
Form 1 - Abstraction (acute record)
Details
Do NOT code the actual Revised Trauma Score. Computer will calculate Revised Trauma Score from these data and the GCS.
RESPIRATORY RATE – code actual rate per minute (use 3 characters) (Range = 0 to160)
If the patient was bagged or on mechanical ventilation, and a respiratory rate was recorded, code the respiratory rate that was recorded.
If the patient was bagged or on mechanical ventilation, and a respiratory rate was not recorded, code the respiratory rate as “888 - Unmeasurable”
If a range rather than a single score is given for Respiratory Rate or Systolic Blood Pressure, code as unknown.
SYSTOLIC BLOOD PRESSURE – code actual blood pressure (use 3 characters) (Range = 0 to 280)
Do not use arterial blood pressure.
If both manual and automated blood pressures are recorded on admission to the ER, use the systolic blood pressure recorded on the Revised Trauma Score entered into the trauma registry. This can be found sometimes in the trauma flow-sheets. If unable to locate, use the manual blood pressure.
Variables
Form Type | Variable | ID | Question | History |
|---|---|---|---|---|
Form 1 | RTSBP | 550 | Systolic blood pressure at admission to ED: | 1989-10-01 - Variable Added |
Form 1 | RTSResp | 551 | Respiratory rate at admission to ED: | 1989-10-01 - Variable Added |
Codes and Values
ID | Code | Description |
|---|---|---|
550 | 6666 | Variable Did Not Exist |
550 | 8888 | Unmeasurable |
550 | 9999 | Unknown |
551 | 6666 | Variable Did Not Exist |
551 | 8888 | Unmeasurable: Bagged or on mechanical ventilation |
551 | 9999 | Unknown |
History
Date | Description |
|---|---|
1995-01-01 | Deleted NOTE : "respiratory effort" and "capillary refill". |
1998-04-15 | Changed CODE : removed "bagged" from description for RTSBP. |
1999-04-01 | Added NOTE : that ED refers to Model System ED. |
1999-04-20 | Changed CODE : added mechanical ventilation to "888 - unmeasurable" code for respiration. |
1999-04-20 | Added NOTE : regarding values reported in ranges. |
2009-10-01 | Changed DEFINITION : Data from non model systems emergency departments may be used if not admitted to model systems facility within the first 24 hours. Change corresponds with expansion of inclusion criteria to 72 hours. |
2018-01-15 | Added NOTE : do not use arterial BP. |
2018-01-25 | Added NOTE : do not code the actual Revised Trauma Score. |
2018-04-01 | Added NOTE : regarding coding of a patient who is bagged or on mechanical ventilation. |
2018-05-23 | Deleted NOTE : regarding how to code if a range is given |
2018-05-23 | Added NOTE : to code as unknown if range is given for resp rate or BP |
2018-07-01 | Added NOTE : if the patient was bagged or on mechanical ventilation, and a respiratory rate was recorded, code the respiratory rate that was recoded.
|
2018-10-01 | Added NOTE : if both manual and automated blood pressures are recorded on admission to the ER, use the systolic blood pressure recorded on the Revised Trauma Score entered into the trauma registry. This can be found sometimes in the trauma flowsheets. If unable to locate, use the manual blood pressure. |