Massachusetts ambulance trip record information system (matris) Effective October 7, 2013 matris version 6
|
|  Yüklə 1.08 Mb.
|
1380 OB/Gyn 1385 Psych 1390 Pulmonary 1395 Renal 1400 Skin Additional Information ● Possible Injury (E09_04), Chief Complaint Anatomic Location (E09_11), Chief Complaint Organ System (E09_12), and Primary Symptom (E09_13) are required to calculate the Reason for Encounter ● This data element is to be completed by EMS personnel at the EMT-Paramedic level or higher Uses ● A component of the EMS Medical Record: Patient Care Report ● Allows for the calculation of the "EMS Reason for Encounter" used to further describe the EMS patient population Data Collector ● EMS personnel Other Associated Elements E00 Common Null Values E01_01 Patient Care Report Number Section E09 Situation MATRIS Version 1.6 (based on 2006 NHTSA Uniform PreHospital Dataset V.2.2.1) PRIMARY SYMPTOM E09_13 Data Format [combo] single-choice National Element Definition The primary sign and symptom present in the patient or observed by EMS personnel XSD Data Type xs:integer XSD Domain (Simple Type) PrimarySymptom Multiple Entry Configuration No Accepts Null Yes Required in XSD Yes Field Values -25 Not Applicable -15 Not Reporting -20 Not Recorded 1405 Bleeding 1410 Breathing Problem 1415 Change in responsiveness 1420 Choking 1425 Death 1430 Device/Equipment Problem 1435 Diarrhea 1440 Drainage/Discharge 1445 Fever 1450 Malaise 1455 Mass/Lesion 1460 Mental/Psych 1465 Nausea/Vomiting 1470 None 1475 Pain 1480 Palpitations 1485 Rash/Itching 1490 Swelling 1495 Transport Only 1500 Weakness 1505 Wound Additional Information ● Possible Injury (E09_04), Chief Complaint Anatomic Location (E09_11), Chief Complaint Organ System (E09_12), and Primary Symptom (E09_13) are required to calculate the Reason for Encounter Uses ● A component of the EMS Medical Record: Patient Care Report ● Allows data to be sorted based on the patient's primary symptom ● Allows data to describe the patient's primary symptom ● Allows for the calculation of the "EMS Reason for Encounter" used to further describe 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 52 Signs and Symptoms Present Section E09 Situation MATRIS Version 1.6 (based on 2006 NHTSA Uniform PreHospital Dataset V.2.2.1) OTHER ASSOCIATED SYMPTOMS E09_14 Data Format [combo] multiple-choice National Element Definition Other symptoms identified by the patient or observed by EMS personnel XSD Data Type xs:integer XSD Domain (Simple Type) OtherAssociatedSymptoms Multiple Entry Configuration Yes Accepts Null Yes Required in XSD Yes Field Values -25 Not Applicable -15 Not Reporting -20 Not Recorded 1510 Bleeding 1515 Breathing Problem 1520 Change in responsiveness 1525 Choking 1530 Obvious Signs of Death 1535 Device/Equipment Problem 1540 Diarrhea 1545 Drainage/Discharge 1550 Fever 1555 Malaise 1560 Mass/Lesion 1565 Mental/Psych 1570 Nausea/Vomiting 1575 None 1580 Pain 1585 Palpitations 1590 Rash/Itching 1595 Swelling 1600 Transport Only 1605 Weakness 1610 Wound Additional Information ● This data element is used for Bioterrorism Syndromic Surveillance Uses ● A component of the EMS Medical Record: Patient Care Report ● Allows data to be sorted based on the patient's primary symptom ● Allows data to describe the patient's associated symptoms ● Allows for potential bio-terrorism surveillance based on the symptomatic presentation of the EMS Patient combined with other data points Data Collector ● EMS personnel Other Associated Elements E00 Common Null Values E01_01 Patient Care Report Number References in NHTSA Version 1 Essential Element 52 Signs and Symptoms Present Section E09 Situation MATRIS Version 1.6 (based on 2006 NHTSA Uniform PreHospital Dataset V.2.2.1) PROVIDERS PRIMARY IMPRESSION E09_15 Data Format [combo] single-choice National Element Definition The EMS personnel’s impression of the patient’s primary problem or most significant condition which led to the management given to the patient (treatments, medications, or procedures).
Essential Element 50 Providers Impression References to Other Databases ● NFIRS 5.0 EMS Module; Title: Provider Impression/Assessment; The emergency providers single most important impression/assessment which drove the choice of treatment; [combo] Abdominal Pain = 10, Airway Obstruction = 11, Allergic Reaction, excludes stings & venomous bites = 12, Altered Level of Consciousness = 13, Behavioral-Mental Status, Psychiatric Disorder = 14, Burns = 15, Cardiac Arrest = 16, Cardiac Dysrhythmia = 17, Chest Paid = 18, Diabetic Symptom = 19, Do Not Resuscitate = 20, Electrocution = 21, General Illness = 2, Hemorrhaging/Bleeding = 23, Hyperthermia = 24, Hypothermia = 25, Hypovolemia = 26, Inhalation Injury, Toxic Gases = 27, Obvious Death = 28, Overdose/Poisoning = 29, Pregnancy/OB = 30, Respiratory Arrest = 31, Respiratory Distress = 32, Seizure = 33, Sexual Assault = 34, Sting/Bite = 35, Stroke/CVA = 36, Syncope, Fainting = 37, Trauma = 38, Other Impression/Assessment = 00, None/No patient or refused Treatment = NN
The EMS personnel’s impression of the patient’s secondary problem or which led to the management given to the patient (treatments, medications, or procedures).
Essential Element 50 Providers Impression Section E09 Situation MATRIS Version 1.6 (based on 2006 NHTSA Uniform PreHospital Dataset V.2.2.1) Section E10 Situation/ Trauma Section E10 Situation/ Trauma MATRIS Version 1.6 (based on 2006 NHTSA Uniform PreHospital Dataset V.2.2.1) CAUSE OF INJURY E10_01 Data Format [combo] single-choice National Element Definition The category of the reported/suspected external cause of the injury XSD Data Type xs:integer XSD Domain (Simple Type) CauseOfInjury Multiple Entry Configuration No Accepts Null Yes Required in XSD Yes Field Values -25 Not Applicable -15 Not Reporting -20 Not Recorded 9500 Aircraft related accident (E84X.0) 9505 Bicycle Accident (E826.0) 9510 Bites (E906.0) 9515 Chemical poisoning (E86X.0) 9520 Child battering (E967.0) 9525 Drowning (E910.0) 9530 Drug poisoning (E85X.0) 9535 Electrocution (non-lightning) (E925.0) 9540 Excessive Cold (E901.0) 9545 Excessive Heat (E900.0) 9550 Falls (E88X.0) 9555 Fire and Flames (E89X.0) 9560 Firearm assault (E965.0) 9565 Firearm injury (accidental) (E985.0) 9570 Firearm self inflicted (E955.0) 9575 Lightning (E907.0) 9580 Machinery accidents (E919.0) 9585 Mechanical Suffocation (E913.0) 9590 Motor Vehicle non-traffic accident (E82X.0) 9595 Motor Vehicle traffic accident (E81X.0) 9600 Motorcycle Accident (E81X.1) 9605 Non-Motorized Vehicle Accident (E848.0) 9610 Pedestrian traffic accident (E814.0) 9615 Radiation exposure (E926.0) 9620 Rape (E960.1) 9625 Smoke Inhalation (E89X.2) 9630 Stabbing/Cutting Accidental (E986.0) 9635 Stabbing/Cutting Assault (E966.0) 9640 Struck by Blunt/Thrown Object (E968.2) 9645 Venomous stings (plants, animals) (E905.0) 9650 Water Transport accident (E83X.0) Additional Information ● Complete only if Possible Injury (E09_04) is “Yes” ● ICD-9 Codes were retained over ICD-10 due to CMS’s continued use of ICD-9 in the EMS Condition Codes Uses ● A component of the EMS Medical Record: Patient Care Report ● Allows data to be sorted based on the traumatic cause of injury ● Allows data to describe the cause of a traumatic event Data Collector ● EMS personnel if Possible Injury (E09_04) is answered Yes Other Associated Elements E00 Common Null Values E01_01 Patient Care Report Number References in NHTSA Version 1 Essential Element 49 Cause of Injury References to Other Databases ● NFIRS 5.0 EMS Module; Title: Cause of Illness/Injury; The immediate cause or condition responsible for the injury or illness; Pick-List: Chemical Exposure = 10, Drug Poisoning = 11, Fall = 12, Aircraft Related = 13, Bite, Includes Animal Bites = 14, Bicycle Accident = 15, Building Collapse/Construction Accident = 16, Downing = 17, Electrical Shock = 18, Cold = 19, Heat = 20, E explosives - 21, Fire and Flames - 22. Firearm = 23, Fireworks = 25, Lightning = 26, Machinery = 27, Mechanical Suffocation = 28, Motor Vehicle Accident = 29, Motor Vehicle Accident, Pedestrian = 30, Non-Traffic Vehicle (off road) Accident = 31, Physical Assault/Abuse = 32, Scalds/Other Thermal = 33, Smoke Inhalation = 34, Stabbing Assault = 35, Venomous Sting = 36, Water Transport = 37, Other Cause of Injury/Illness = 00, Unknown Cause of Injury/Illness = UU
The mechanism of the event which caused the injury. XSD Data Type xs:integer XSD Domain (Simple Type) MechanismOfInjury Multiple Entry Configuration Yes Accepts Null Yes Required in XSD No Field Values -25 Not Applicable -15 Not Reporting -20 Not Recorded 2035 Blunt 2040 Burn 2045 Other 2050 Penetrating Additional Information ● Complete only if Possible Injury (E09_04) is “Yes” Uses ● A component of the EMS Medical Record: Patient Care Report ● Important component of an EMS Medical Record to identify issues of clinical care and agency performance and delivery ● Used to better define injury cause and describe injury patterns within and EMS community Data Collector ● EMS personnel if Possible Injury (E09_04) is answered Yes Other Associated Elements E00 Common Null Values E01_01 Patient Care Report Number Section E10 Situation/ Trauma MATRIS Version 1.6 (based on 2006 NHTSA Uniform PreHospital Dataset V.2.2.1) VEHICULAR INJURY INDICATORS E10_04 Data Format [combo] multiple-choice Definition The kind of risk factor predictors associated with the vehicle involved in the incident XSD Data Type xs:integer XSD Domain (Simple Type) VehicularInjuryIndicators Multiple Entry Configuration Yes Accepts Null Yes Required in XSD No Field Values -25 Not Applicable -15 Not Reporting -20 Not Recorded 2055 Dash Deformity 2060 DOA Same Vehicle 2065 Ejection 2070 Fire 2075 Rollover/Roof Deformity 2080 Side Post Deformity 2085 Space Intrusion >1 foot 2090 Steering Wheel Deformity 2095 Windshield Spider/Star Additional Information ● Complete only if Possible Injury (E09_04) is “Yes” Uses ● A component of the EMS Medical Record: Patient Care Report ● Used to better define injury cause and describe injury patterns within and EMS community Data Collector ● EMS personnel if Possible Injury (E09_04) is answered Yes and there is a vehicle involved Other Associated Elements E00 Common Null Values E01_01 Patient Care Report Number Section E10 Situation/ Trauma MATRIS Version 1.6 (based on 2006 NHTSA Uniform PreHospital Dataset V.2.2.1) AREA OF THE VEHICLE IMPACTED BY THE COLLISION E10_05 Data Format [combo] multiple-choice Definition The area or location of impact on the vehicle XSD Data Type xs:integer XSD Domain (Simple Type) AreaOfVehicleImpact Multiple Entry Configuration Yes Accepts Null Yes Required in XSD No Field Values -25 Not Applicable -15 Not Reporting -20 Not Recorded 2100 Center Front 2105 Center Rear 2110 Left Front 2115 Left Rear 2120 Left Side 2125 Right Front 2130 Right Rear 2135 Right Side 2140 Roll Over Additional Information ● Complete only if Possible Injury (E09_04) is “Yes” Uses ● A component of the EMS Medical Record: Patient Care Report ● Used to better define injury cause and describe injury patterns within and EMS community Data Collector ● EMS personnel if Possible Injury (E09_04) is answered Yes and there is a vehicle involved Other Associated Elements E00 Common Null Values E01_01 Patient Care Report Number Section E10 Situation/ Trauma MATRIS Version 1.6 (based on 2006 NHTSA Uniform PreHospital Dataset V.2.2.1) SEAT ROW LOCATION OF PATIENT IN VEHICLE E10_06 Data Format [text] Definition The seat row location of the patient in vehicle at the time of the crash with the front seat numbered as 1. XSD Data Type xs:integer XSD Domain (Simple Type) SeatRowLocation Multiple Entry Configuration No Accepts Null No Required in XSD No Minimum Constraint 1 Maximum Constraint 15 XSD Structure: E10_06 and E10_07 are members of E10_06_0 Position of Patient Structure Field Values ● Relevant Value for Data Element & Patient Care ● If a value of 50 is passed, the location is designated "Cargo Area" ● MATRIS Runform field contains 1-50 Additional Information ● Complete only if Possible Injury (E09_04) is “Yes” ● Could be configured as a single choice combo box ● Numbered to take into account large vehicles such as buses or vans (1 = Front) or (Cargo Area = 50) Uses ● A component of the EMS Medical Record: Patient Care Report ● Important component of an EMS Medical Record to identify issues of clinical care and agency performance and delivery ● Used to better define injury cause and describe injury patterns within and EMS community Data Collector ● EMS personnel if Possible Injury (E09_04) is answered Yes and there is a vehicle involved Other Associated Elements E01_01 Patient Care Report Number E10_07 Position of Patient in the Seat of the Vehicle Section E10 Situation/ Trauma MATRIS Version 1.6 (based on 2006 NHTSA Uniform PreHospital Dataset V.2.2.1) USE OF OCCUPANT SAFETY EQUIPMENT E10_08 Data Format [combo] multiple-choice Definition Safety equipment in use by the patient at the time of the injury XSD Data Type xs:integer XSD Domain (Simple Type) UseOfOccupantSafetyEquipment Multiple Entry Configuration Yes Accepts Null Yes Required in XSD No |