|Data Elements for Emergency Department Systems - Release 1.0 (Centers for Disease Control and Prevention, 1997, 274 p.)|
|SECTION 5 - ED HISTORY AND PHYSICAL EXAMINATION DATA|
ED PRACTITIONER EVALUATION
Beginning date and time of first evaluation by ED practitioner responsible for performing brief screening evaluation, simultaneous assessment and resuscitation, or more comprehensive history and physical examination.
Data about the date and time of health services delivery are needed to maintain continuity of care for the ED patient and for aggregate use in ED administration, quality-of-care monitoring and evaluation, and health services research.
An emergency physician usually conducts this evaluation, but it may be conducted by another practitioner, such as an advanced practice nurse (e.g., clinical nurse specialist, nurse practitioner), physician assistant, resident, or intern, or by a supervised student practitioner (e.g., medical student, physician assistant student).
This evaluation is not the acuity, triage, or primary nurse assessment.
Data Type (and Field Length)
TS - time stamp (26).
See the definition of TS in the Technical Notes at the end of this document.
Data Standards or Guidelines
E1744-95 (ASTM, 1995).