DOCUMENTATION CLARIFICATION FOR TRAUMA REGISTRY DATA

                                                           

 PAST MEDICAL HISTORY                                                   

                                                           

DOCUMENT RECENT CHEST PAIN / ANGINA                                                       

                                                           

DOCUMENTATION FOR CVA PATIENTS IF RESIDUAL DEFICIT PRESENT                                            

                                                           

DOCUMENTATION OF MI WITHIN 6 MONTHS VS. LONGER                                                       

                                                           

"SUBSTANCE USE DISORDER" OR "ALCOHOL USE DISORDER" WHEN 2 OR MORE OF FOLLOWING:           

·         Loss of control over drug/alcohol use                                                         

·         Investing large amounts of time obtaining substances                                                     

·         Cravings                                                          

·         Continued use in spite of relationship conflicts                                                     

·         Risk-taking, such as using while driving                                                      

·         Continued use in the face of developing health problems                                                           

·         Increasing tolerance levels                                                   

·         Loss of interest in activities once enjoyed                                                   

·         Withdrawal episodes                                                 

·         Failed attempts to stop using                                                           

·         Failing to meet obligations (work, home, school)                                                   

                                                           

HOSPITAL EVENTS / COMPLICATIONS                                                     

                                                           

ACUTE KIDNEY INJURY – STAGE 3--ABRUPT DECREASE IN KIDNEY FUNCTION WHILE INPATIENT                                                          

*SCr 3 TIME BASELINE OR

SCr TO ≥ 4.0 mg/dl OR

INITIATION OF RENAL REPLACEMENT THERAPY OR

URINE OUTPUT <.3 ML/KG/H FOR > 24 HOURS, OR ANURIA FOR > 12 HOURS                                                         

ALCOHOL WITHDRAWAL SYNDROME –  MUST BE DOCUMENTED IN CHART                                                 

                                                           

SUPERFICIAL INCISIONAL SURGICAL SITE INFECTION

SKIN AND SUBCUTANEOUS INCISION INFECTION WITHIN 30 DAYS OF OPERATIVE PROCEDURE                                                                         

DEEP SURGICAL SITE INFECTION – REQUIRES DOCUMENTATION                                                      

*INFECTION WITH 30-90 DAYS (TYPE OF SURGERY DEPENDENT) AND                                            

*INVOLVING DEEP SOFT TISSUES AND                                                     

*DRAINAGE, DEHISCENCE OR REQUIRING OPEN ASPIRATION AND                                                     

*FEVER, TENDERNESS, AND/OR ABSCESS                                                

                                                           

ORGAN / SPACE SURGICAL SITE INFECTION – WITHIN 30 -90 DAYS OF PROCEDURE                                  

INVOLVING DEEPER THAN FASCIAL/MUSCLE LAYERS                                                   

DUE TO PROCEDURE

DRAINAGE, CULTURE OR ABSCESS    

Published 12/20/18 (T Cooper, S Priest, A Bernard); Reviewed 9/26/24 (A Bernard, T Cooper)