|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|
Brief description of injury incident that precipitated patient's ED visit.
Data describing the cause of injury are used in evaluating and treating individual patients, and these data are useful for public health surveillance and clinical and epidemiologic research.
Injury includes blunt and penetrating injuries, blast injuries, burns, electrical or radiation injuries, bites, stings, aspiration of foreign objects, foreign objects entering body orifices, poisonings, toxic exposures, adverse drug reactions, drownings, near-drownings, strangulations, exposures to environmental extremes, bodily overexertions or strains, maltreatment, and sexual assault. Injury excludes aspiration of vomitus or mucus. This data element is intended for use in describing the injury that led to the patients ED visit, and its intended use encompasses initial treatments, treatments of injury sequelae (late effects), patient transfers from other health care facilities, and referrals from elsewhere within the hospital. This information is not intended for use in a scheduled return ED visit following initial treatment (e.g., suture removal). Researchers can use the injury incident description in two ways: 1) they can read unaltered text or search it electronically for words or phrases of interest; 2) they can apply injury coding and classification systems to existing text entries.
Data Type (and Field Length)
ST - string data (200).
Enter a concise text description of the injury-producing event or circumstance, including the mechanism by which bodily harm was produced and what the patient was doing when injured. Specify the agent or class of agents in poisonings, toxic exposures, and adverse drug reactions. In cases of assault or maltreatment, characterize the relationship between the patient and the person or persons who caused the injury.
Beaten by boyfriend with a two-by-four piece of wood during domestic dispute.
Motorcyclist skidded on highway and struck telephone pole.
Data Standards or Guidelines