Massachusetts ambulance trip record information system (matris) Effective October 7, 2013 matris version 6
|
|  Yüklə 1.08 Mb.
|
Other Associated Elements E00 Common Null Values E01_01 Patient Care Report Number E06_01 Last Name E06_01 Last Name Section E12 Medical History MATRIS Version 1.6 (based on 2006 NHTSA Uniform PreHospital Dataset V.2.2.1) MEDICAL/SURGICAL HISTORY E12_10 Data [combo or text] multiple-choice Definition The patient’s pre-existing medical and surgery history of the patient XSD Data Type xs:string XSD Domain (Simple Type) MedicalSurgicalHistory Multiple Entry Configuration Yes Accepts Null Values Yes Required in XSD No Minimum Constraint 2 Maximum Constraint 30 Field Values -25 Not Applicable -15 Not Reporting -20 Not Recorded ● Relevant Value for Data Element & Patient Care A list is available from OEMS Additional Information ● A Medical/Surgical History list should be created to serve as a listbox which can contain any ICD-9 coded diagnosis or procedure ● The field should store the values of the ICD-9 codes since CMS has not adopted ICD-10 level codes at the time of this document
Uses ● Part of an EMS Medical Record Data Collector ● EMS personnel or electronically through linkage with a pre-existing Patient Care Report or hospital database Other Associated Elements E00 Common Null Values E01_01 Patient Care Report Number E06_01 Last Name References in NHTSA Version 1 Essential Element 51 Pre-Existing Condition Section E12 Medical History MATRIS Version 1.6 (based on 2006 NHTSA Uniform PreHospital Dataset V.2.2.1) CURRENT MEDICATIONS E12_14 Data [combo or text] multiple-choice Definition The medications the patient currently takes XSD Data Type xs:string XSD Domain (Simple Type) CurrentMedicationName Multiple Entry Configuration Yes, via structure Accepts Null Values No Required in XSD No Minimum Constraint 2 Maximum Constraint 30 XSD Structure: (1) E12_14, E12_15, E12_16, and E12_17 are all members of E12_14_0 Current Medications Structure. (2) E12_15 and E12_16 are members of E12_15_0 Current Medication Dose Structure
A list is available from OEMS Additional Information ● A Drug List should be created to serve as a listbox which can contain any generic or trade name of a drug approved by the FDA ● Alternatively, the drugs may be entered as a multiple entry text configuration ● The Drug List should also include “None” Uses ● Part of an EMS Medical Record Data Collector ● EMS personnel or electronically through linkage with a pre-existing Patient Care Report or hospital database Other Associated Elements E01_01 Patient Care Report Number E12_15 Current Medication Dose E12_16 Current Medication Dosage Unit E12_17 Current Medication Administration Route Section E12 Medical History MATRIS Version 1.6 (based on 2006 NHTSA Uniform PreHospital Dataset V.2.2.1) ALCOHOL/DRUG USE INDICATORS E12_19 Data Format [combo] multiple-choice National Element Definition Indicators for the potential use of Alcohol or Drugs by the patient. XSD Data Type xs:integer XSD Domain (Simple Type) AlcoholDrugUseIndicators Multiple Entry Configuration Yes Accepts Null Yes Required in XSD Yes Field Values -25 Not Applicable -15 Not Reporting -20 Not Recorded 2985 Smell of Alcoholic Beverage on Breath/About Person 2990 Patient Admits to Alcohol Use 2995 Patient Admits to Drug Use 3000 Alcohol and/or Drug Paraphernalia at Scene 3001 No Apparent Alcohol/Drug Use Uses ● A component of the EMS Medical Record: Patient Care Report ● Allows data to be sorted based on alcohol/drug use indicators ● Allows data to describe Alcohol and Drug use within the EMS patient population Data Collector ● EMS personnel Other Associated Elements E00 Common Null Values E01_01 Patient Care Report Number References in NHTSA Version 1 Essential Element 57 Suspected Alcohol/Drug Use References to Other Databases ● NFIRS 5.0 EMS Module; Title: Human Factors; Describes the human factors that contributed to the patient’s injury; Pick- List: Asleep = 1, Unconscious = 2, Possibly Impaired by Alcohol = 3, Possibly Impaired by Other Drug or Chemical = 4, Possibly Mentally Disabled = 5, Physically Disabled = 6, Physically Restrained = 7, Unattended or Unsupervised Person, Included are too young to act = 8, None or No Human Factors = N
Assessment/ Vital Signs Section E14 Assessment/ Vital Signs MATRIS Version 1.6 (based on 2006 NHTSA Uniform PreHospital Dataset V.2.2.1) DATE/TIME VITAL SIGNS TAKEN E14_01 Data Format [date/time] Definition Date/Time Vital Signs Taken XSD Data Type xs:dateTime XSD Domain (Simple Type) DateTime Multiple Entry Configuration Yes, via structure Accepts Null Yes, but null value is blank or empty Required in XSD No Minimum Constraint 1,990 Maximum Constraint 2,030 XSD Structure: Each element is section E14 is associated with a E14_01 Date/Time Field Values ● Relevant Value for Data Element & Patient Care Additional Information ● If the date/time is electronically stored within a database or transmitted via XML as a “tick”, the referenced variables may also be used ● Multiple Entry Configuration to allow multiple sets of Vital Signs Uses ● Part of an EMS Medical Record ● Provides documentation of Assessment and Care ● Used in Quality Management for the evaluation of Care and EMS Agency Performance Data Collector ● EMS personnel or may be provided electronically through a medical device Other Associated Elements E01_01 Patient Care Report Number References to Other Databases ● NFIRS 5.0 EMS Module; Title: Patient Pulse; Presence of a Pulse at the time of patient transfer to another service.; Pick- List: Pulse on Transfer = 1, No; Pulse of Transfer = 2
The initial cardiac rhythm of the patient as interpreted by EMS personnel XSD Data Type xs:integer XSD Domain (Simple Type) CardiacRythm Multiple Entry Configuration (1) Yes, via structure. (2) Accepts Null Values Yes Yes for each E14_01 Date/Time
XSD Structure: Each element is section E14 is associated with a E14_01 Date/Time Field Values -25 Not Applicable -15 Not Reporting -20 Not Recorded 3005 12 Lead ECG-Anterior Ischemia 3010 12 Lead ECG-Inferior Ischemia 3015 12 Lead ECG-Lateral Ischemia 3020 Agonal/Idioventricular 3025 Artifact 3030 Asystole 3035 Atrial Fibrillation/Flutter 3040 AV Block-1st Degree 3045 AV Block-2nd Degree-Type 1 3050 AV Block-2nd Degree-Type 2 3055 AV Block-3rd Degree 3060 Junctional 3065 Left Bundle Branch Block 3070 Normal Sinus Rhythm 3075 Other 3080 Paced Rhythm 3085 PEA 3090 Premature Atrial Contractions 3095 Premature Ventricular Contractions 3100 Right Bundle Branch Block 3105 Sinus Arrhythmia 3110 Sinus Bradycardia 3115 Sinus Tachycardia 3120 Supraventricular Tachycardia 3125 Torsades De Points 3130 Unknown AED Non-Shockable Rhythm 3135 Unknown AED Shockable Rhythm 3140 Ventricular Fibrillation 3145 Ventricular Tachycardia Uses ● Part of an EMS Medical Record ● Provides documentation of Assessment and Care ● Used in Quality Management for the evaluation of Care and EMS Agency Performance Data Collector ● EMS personnel or may be provided electronically through a medical device Other Associated Elements E00 Common Null Values E01_01 Patient Care Report Number E14_01 Date/Time Vital Signs Taken References in NHTSA Version 1 Desirable Element 66 Initial Cardiac Rhythm Section E14 Assessment/Vital Signs MATRIS Version 1.6 (based on 2006 NHTSA Uniform PreHospital Dataset V.2.2.1) SBP (SYSTOLIC BLOOD PRESSURE) E14_04 Data Format [number] Definition The patient's systolic blood pressure XSD Data Type xs:integer XSD Domain (Simple Type) SBP Multiple Entry Configuration Yes, via structure Accepts Null Yes, but null value is blank or empty Required in XSD No Minimum Constraint 0 Maximum Constraint 400 XSD Structure: (1) Each element is section E14 is associated with a E14_01 Date/Time. (2) E14_04, E14_05, and E14_06 are all members of E14_04_0 Blood Pressure Structure
Essential Element 70 Systolic Blood Pressure Section E14 Assessment/Vital Signs MATRIS Version 1.6 (based on 2006 NHTSA Uniform PreHospital Dataset V.2.2.1) DBP (DIASTOLIC BLOOD PRESSURE) E14_05 Data Format [number] Definition The patient's diastolic blood pressure XSD Data Type xs:integer XSD Domain (Simple Type) DBP Multiple Entry Configuration Yes, via structure Accepts Null Yes, but null value is blank or empty Required in XSD No Minimum Constraint 0 Maximum Constraint 300 XSD Structure: (1) Each element is section E14 is associated with a E14_01 Date/Time. (2) E14_04, E14_05, and E14_06 are all members of E14_04_0 Blood Pressure Structure
Essential Element 71 Diastolic Blood Pressure Section E14 Assessment/Vital Signs MATRIS Version 1.6 (based on 2006 NHTSA Uniform PreHospital Dataset V.2.2.1) PULSE RATE E14_07 Data Format [number] Definition The patient's pulse rate, palpated or auscultated, expressed as a number per minute XSD Data Type xs:integer XSD Domain (Simple Type) PulseRate Multiple Entry Configuration Yes, via structure Accepts Null Yes, but null value is blank or empty Required in XSD No Minimum Constraint 0 Maximum Constraint 500 XSD Structure: Each element is section E14 is associated with a E14_01 Date/Time Field Values ● Relevant Value for Data Element & Patient Care Additional Information ● Could be collected from Device Pulse Rate (E21_13) Uses ● Part of an EMS Medical Record ● Provides documentation of Assessment and Care ● Used in Quality Management for the evaluation of Care and EMS Agency Performance Data Collector ● EMS personnel or may be provided electronically through a medical device Other Associated Elements E01_01 Patient Care Report Number E14_01 Date/Time Vital Signs Taken References in NHTSA Version 1 Essential Element 65 Pulse Rate References to Other Databases ● NFIRS 5.0 EMS Module; Title: Patient Pulse; Presence of a Pulse at the time of patient transfer to another service.; Pick- List: Pulse on Transfer = 1, No; Pulse of Transfer = 2
The patient's oxygen saturation XSD Data Type xs:integer XSD Domain (Simple Type) PulseOximetry Multiple Entry Configuration Yes, via structure Accepts Null Yes, but null value is blank or empty Required in XSD No Minimum Constraint 0 Maximum Constraint 100 XSD Structure: Each element is section E14 is associated with a E14_01 Date/Time Field Values ● Relevant Value for Data Element & Patient Care Additional Information ● Could be collected from Device Pulse Oximetry (E21_17) Uses ● Part of an EMS Medical Record ● Provides documentation of Assessment and Care ● Used in Quality Management for the evaluation of Care and EMS Agency Performance Data Collector ● EMS personnel or may be provided electronically through a medical device Other Associated Elements E01_01 Patient Care Report Number E14_01 Date/Time Vital Signs Taken Section E14 Assessment/Vital Signs MATRIS Version 1.6 (based on 2006 NHTSA Uniform PreHospital Dataset V.2.2.1) RESPIRATORY RATE E14_11 Data Format [number] Definition The patient's respiratory rate expressed as a number per minute XSD Data Type xs:integer XSD Domain (Simple Type) RespiratoryRate Multiple Entry Configuration Yes, via structure Accepts Null Yes, but null value is blank or empty Required in XSD No Minimum Constraint 0 Maximum Constraint 100 XSD Structure: Each element is section E14 is associated with a E14_01 Date/Time Field Values ● Relevant Value for Data Element & Patient Care Additional Information ● Could be collected from Device Respiratory Rate (E21_16) Uses ● Part of an EMS Medical Record ● Provides documentation of Assessment and Care ● Used in Quality Management for the evaluation of Care and EMS Agency Performance Data Collector ● EMS personnel or may be provided electronically through a medical device Other Associated Elements E01_01 Patient Care Report Number E14_01 Date/Time Vital Signs Taken References in NHTSA Version 1 Essential Element 68 Respiratory Rate Section E14 Assessment/Vital Signs MATRIS Version 1.6 (based on 2006 NHTSA Uniform PreHospital Dataset V.2.2.1) GLASGOW COMA SCORE-EYE E14_15 Data Format [number] Definition The patient's Glasgow Coma Score Eye opening XSD Data Type xs:integer XSD Domain (Simple Type) GCSEye Multiple Entry Configuration Yes, via structure Accepts Null Yes, but null value is blank or empty Required in XSD No Minimum Constraint 1 Maximum Constraint 4 XSD Structure: (1) Each element is section E14 is associated with a E14_01 Date/Time. (2) E14_15, E14_16, E14_17, and E14_18 are all members of E14_15_0 GCS Score Structure
Essential Element 73 Glasgow Eye Opening Component Section E14 Assessment/Vital Signs MATRIS Version 1.6 (based on 2006 NHTSA Uniform PreHospital Dataset V.2.2.1) GLASGOW COMA SCORE-VERBAL E14_16 Data Format [number] Definition The patient's Glasgow Coma Score Verbal XSD Data Type xs:integer XSD Domain (Simple Type) GCSVerbal Multiple Entry Configuration Yes, via structure Accepts Null Yes, but null value is blank or empty Required in XSD No Minimum Constraint 1 Maximum Constraint 5 XSD Structure: (1) Each element is section E14 is associated with a E14_01 Date/Time. (2) E14_15, E14_16, E14_17, and E14_18 are all members of E14_15_0 GCS Score Structure
Essential Element 74a Glasgow Verbal Component For patients >5 years Essential Element 74b Glasgow Verbal Component For patients 2-5 years Essential Element 74c Glasgow Verbal Component for patients 0-23 months Section E14 Assessment/Vital Signs MATRIS Version 1.6 (based on 2006 NHTSA Uniform PreHospital Dataset V.2.2.1) |