North Carolina Administrative Code
Title 10A - HEALTH AND HUMAN SERVICES
Chapter 41 - EPIDEMIOLOGY HEALTH
Subchapter A - COMMUNICABLE DISEASE CONTROL
Section .0100 - COMMUNICABLE DISEASE CONTROL
Section 41A .0105 - HOSPITAL EMERGENCY DEPARTMENT DATA REPORTING

(1) Patient record number or other unique identification number;

(2) Patient date of birth and age;

(3) Patient's sex;

(4) City of residence;

(5) County of residence;

(6) Five digit ZIP code;

(7) Alpha numeric patient control number assigned by the hospital for each record (the Visit Identification Number);

(8) Emergency department facility identification number;

(9) Projected payor source;

(10) Date and time of emergency department visit (first documented time);

(11) Mode of transport to the emergency department;

(12) PreMIS identification number, if transported by EMS;

(13) Chief complaint;

(14) Initial temperature reading and route;

(15) Initial systolic and initial diastolic blood pressure;

(16) Triage Notes (brief description of patient's/family's self-reported illness episode, including symptoms, duration of symptoms, and reasons for visit [in addition to Chief Complaint] as presented by the patient or family to the triage nurse upon arrival at the emergency department) - this element is optional;

(17) Initial emergency department acuity assessment;

(18) Coded cause of injury (ICD-9-CM, if injury related to diagnosis);

(19) Emergency department procedures, up to ten (CPT or ICD-9-CM or ICD-10-CM);

(20) Emergency department disposition;

(21) Emergency department disposition diagnosis description; and

(22) Emergency department disposition diagnosis codes, one primary and up to ten additional (ICD-9-CM or ICD-10-CM).