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close this bookData Elements for Emergency Department Systems - Release 1.0 (Centers for Disease Control and Prevention, 1997, 274 p.)
close this folderSECTION 5 - ED HISTORY AND PHYSICAL EXAMINATION DATA
View the document5.01 DATE/TIME OF FIRST
View the document5.02 DATE/TIME OF ILLNESS OR INJURY ONSET
View the document5.03 INJURY INCIDENT DESCRIPTION
View the document5.04 CODED CAUSE OF INJURY
View the document5.05 INJURY INCIDENT LOCATION TYPE
View the document5.06 INJURY ACTIVITY
View the document5.07 INJURY INTENT
View the document5.08 SAFETY EQUIPMENT USE
View the document5.09 CURRENT THERAPEUTIC MEDICATION
View the document5.10 CURRENT THERAPEUTIC
View the document5.11 CURRENT THERAPEUTIC MEDICATION DOSE UNITS
View the document5.12 CURRENT THERAPEUTIC MEDICATION SCHEDULE
View the document5.13 CURRENT THERAPEUTIC MEDICATION ROUTE
View the document5.14 ED CLINICAL FINDING TYPE
View the document5.15 ED CLINICAL FINDING
View the document5.16 DATE/TIME ED CLINICAL FINDING OBTAINED
View the document5.17 ED CLINICAL FINDING PRACTITIONER ID
View the document5.18 ED CLINICAL FINDING PRACTITIONER TYPE
View the document5.19 ED CLINICAL FINDING DATA SOURCE

5.01 DATE/TIME OF FIRST

ED PRACTITIONER EVALUATION

Definition

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.

Uses

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.

Discussion

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).

Repetition

No.

Field Values

See the definition of TS in the Technical Notes at the end of this document.

Data Standards or Guidelines

None.

Other References

E1744-95 (ASTM, 1995).