Thursday, December 20, 2018

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)