New Mexico Administrative Code
Title 7 - HEALTH
Chapter 27 - EMERGENCY MEDICAL SERVICES
Part 7 - TRAUMA CARE SYSTEM
Section 7.27.7.14 - APPENDIX C: TRAUMA DATA COLLECTION/ DOCUMENTATION CRITERIA
Universal Citation: 7 NM Admin Code 7.27.7.14
Current through Register Vol. 35, No. 18, September 24, 2024
A. Prehospital
(1) scene calls, first
responders, licensed ground or certified air ambulance services data shall
include:
(a) pre-hospital incident run
number
(b) name or name code, when
available
(c) date of birth when
available
(d) age
(e) sex
(f) social security number when
available
(g) agency identification
number
(h) first agency on scene
(yes/ no)
(i) transporting agency
identification
(j) level of
transporting agency (BLS/ ALS)
(k)
incident county code
(l) date of
incident
(m) time
(i) call received
(ii) dispatched
(iii) arrived at scene
(iv) departed scene
(n) initial systolic blood pressure (if
obtainable, palpable or best pulse)
(o) respiratory rate
(p) Glasgow coma score- (eye, verbal, and
motor when applicable)
(q)
narrative description of the mechanism of injury
(r) meets trauma triage criteria (yes/
no)
(s) extrication
required
(t) safety restraint or
device used
(u) field interventions
done
(v) additional information if
patient died at scene
(i) patient home zip
code
(ii) patient race when
available
(2)
for interfacility transfers, the transporting service shall include:
(a) agency identification number
(b) pre-hospital run sheet number
(c) inter-facility transfer (yes/
no)
(d) mode of
transportation
(e) level of
transportation (BLS/ ALS)
(f)
patient name or name code
(g) date
of birth, when available
(h) social
security number, when available
(i)
age
(j) sex
(k) agency incident number
(l) name of first hospital
(m) name of receiving hospital
(n) time
(i)
depart first hospital
(ii) arrive
at receiving facility
B. Designated Trauma Centers
(1) for designated trauma centers, the data
shall include:
(a) *indicates a data element
currently included in the HTR (Hospital Trauma Registry)
(b) **indicates a data element to be
downloaded to the STR (State Trauma Registry)
(c) **identification of facility
(d) **unique patient identification number
assigned to the patient by the facility
(e) level of transporting agency
(BLS/ALS)
(f) *pre-hospital run
sheet number
(g) **date of ED
arrival
(h) *time of ED
arrival
(i) **date of
incident
(j) **initial
hospital
(k) **facility patient was
transferred from
(2) for
designated trauma centers, patient information shall include:
(a) *name or name code
(b) **date of birth
(c) **sex
(d) **race
(e) **patient's trauma identification number
(same as b above in section 1)
(f)
**social security number
(g) home
zip code
(3) **mechanism
of injury (narrative)
(4) **E Code,
including E Code 849
(5)
**occupational injury (yes/ no)
(6)
**safety restraint/ device used
(7)
time of patient radio report
(8)
**trauma team activated (yes/ no)
(9) activation response times
(a) time of activation
(b) time of call to surgeon
(c) *time of arrival of surgeon in
ED
(d) *time of arrival of
subspecialist
(10)
initial vital signs in ED
(a) **systolic blood
pressure
(b) **respiratory
rate
(c) first
temperature
(d) ** Glasgow coma
score (eye, verbal, and motor)
(11) **ED respiratory status (spontaneous/
intubated)
(12) **ED procedures
performed
(13) *time of ED
discharge
(14) **ED discharge
disposition
(15) *admitting
service
(16) CT scan of head done
(yes/ no)
(a) date of head CT scan
(b) time of head CT scan
(17) for initial surgery
(a) **date and time patient arrived
or
(b) date/ time operation
started
(c) **ICD-9- CM procedure
code
(d) *total cc's PRBC
infused
(18) **length of
primary stay in ICU
(19) *co-
morbidity complications
(20)
disability at acute care discharge
(a)
**feeding
(b)
**locomotion
(c)
**expression
(d) **rehabilitation
potential
(21) **date of
facility discharge
(22) **discharge
disposition
(23) **extended care
facility identification number
(24)
autopsy done (yes/ no)
(25) **date
of death
(26) **organ/tissue donor
(yes/ no)
(27) **final ICD-9
discharge code
(28) *unplanned
readmission
(29) **payer
source
(30) **total billed
charges
C. Office of Medical Investigator- data may include:
(1) name or name code
(2) **date of birth
(3) **social security number
(4) **sex
(5) **race
(6) **date of incident
(7) **date of death
(8) **place of death
(9) home zip code
(10) **medical examiner identification
number
(11) **medical examiner
facility identification number
(12)
**autopsy done
(13) **mechanism of
injury
(14) **organ donor
(15) **cause of death
(16) most recent ICD diagnosis code or
equivalent description
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