Patients who die early after arrival sometimes have low injury severity score (ISS) in the database. Accurate ISS coding is important because it established the predicted mortality and helps accurately reflect trauma center performance. Thorough physical exam and careful documentation is the best way to ensure adequate ISS coding.
ANY OBVIOUS HEAD INJURY
- LOC SINCE INJURED OR DURATION OF LOC KNOWN?
- CONCUSSION GETS UP TO AN AIS OF 3
- CSF LEAK? OBVIOUS FRACTURE? OBVIOUS SKULL BASE IS AIS 3, OPEN DEPRESSED SKULL FRACTURE CAN BE UP TO AN AIS 4
- PENETRAING INJURY TO HEAD OBVIOUSLY DEEPER THAN 2 CM IS AN AIS 5
ANY THORACIC / ABDOMINAL OBVIOUS TRAUMA
- SUCKING CHEST WOUND WITHOUT ANY OTHER INFO IS AIS 4
- PNEUMOTHORAX WITHOUT DESCRIPTION IS AIS 2, IF PERSISTENT AIR LEAK OR MASSIVE AIS 4, IF TENSION AIS 5
- AORTIC LACERATION IS AIS 4, IF MAJOR / 20% BLOOD LOSS IT’S AIS 5 AND IF HEMORRHAGE IS NOT CONTAINED TO THE MEDIASTINUM IT’S AIS 6
- MOST VASCULAR INJURIES UPGRADE ONE AIS POINT FOR BLOOD LOSS >20%
- DIAPHRAGM LACERATION IS AIS 2-4 DEPENDING ON SIZE
- TRAUMATIC ASPHYXIATION IS AIS 3-5, WITH 5 FOR DOCUMENTED ARREST
- HEART LACERATION NFS IS AIS 3, ANY PERFORATION OR ATRIAL RUPTURE IS AIS 5 AND ATRIAL RUPTURE OR MULTIPLE LAC’S IS AN AIS 6
ORGAN INJURIES CAN BE SCORED IF YOU HAVE ANY DETAIL WITH AT LEAST AIS 2
ANY EXTREMITY TRAUMA CAN BE CODED AT SOME LEVEL IF YOU DOCUMENT “OBVIOUS FRACTURE”. THIS ADDS USUALLY AN AIS 2 OR 3 TO THEIR ISS CALCULATION
**CONDITIONS LIKE SHOCK, COAGULOPATHY, ETC. CAN INFLUENCE REIMBURSEMENT SO THOSE SHOULD ALSO BE DOCUMENTED BUT WILL NOT AFFECT ISS SCORES.
March 13, 2022 (Trish Cooper/C Reynolds/A Bernard); reviewed 12-15-23
