TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH
SUBCHAPTER f: EMERGENCY SERVICES AND HIGHWAY SAFETY
PART 550 HEAD AND SPINAL CORD INJURY CODE
SECTION 550.APPENDIX A HEAD AND SPINAL CORD INJURY REPORTING/VIOLENT INJURY REPORTING



Section 550.APPENDIX A  Head and Spinal Cord Injury Reporting/Violent Injury Reporting

 

PART 1

 

Hospital Name

 

code

 

 

Prehospital Number

NA

Unk

 

     /     /     /    

 

 

Crash Number

NA

Unk

 

     /     /     /     /     /     /     /    

 

 

Med. Record Number

NA

Unk

 

     /     /     /     /     /     /     /     /     /    

 

 

Patient Name

 

 

_____________________________________

 

 

 

 

last

first

initial

 

ED Arrival Date

 

 

 

     /     /    

(mo/dd/yy)

 

Birthdate

 

Unk

 

     /     /    

(mo/dd/yy)

 

Age in years

 

Unk

 

     /     /    

(0  =  <1  yr)  Fetus

 

 

Sex

 

Unk

F    M

 

Race*

 

Unk

1  White    2  Black    3  WHisp    4  BHisp

 

 

 

 

5  AmerI    6  PacI    7  Asian    8  Other

 

Injury Date

 

Unk

 

     /     /    

(mo/dd/yy)

 

FIPS Scene

 

Unk

 

     /     /    

 

 

Scene City

 

 

 

 

FIPS Home

 

Unk

 

     /     /    

 

 

Home City

 

 

 

 

E-Code

 

Unk

 

E

     /     /    

 

 

E-Code 849

NA

Unk

 

E

     /     /    

 

 

Work Related

 

Unk

Y    N

 

Safety Equipment*

NA

Unk

1  None    2  Belt/Harness    3  Bag/Belt

 

 

 

 

4  Bag Only    5  Child Seat    6  Helmet

 

 

 

 

7  ProClothes    8  Other

 

* See Instruction Book for table detail

 

PART 2

 

 

 

 

Alcohol

NA

Unk

 

    .    /    

 

 

Drugs*

NA

Unk

N   Y    Amph    Barb    Benz

 

 

 

 

Coc    Marij    Opiate    PCP

 

Glasgow Total

NA

Unk

 

     /    

 

 

Systolic BP

NA

Unk

 

     /     /    

 

 

Resp. Rate

NA

Unk

 

     /     /    

 

 

Resp. Rate Status

NA

Unk

1  Vent    2  Intub.    3  Both

 

Disposition

NA

 

1  Home**    2  AMA    3  Obser    4  Floor

 

 

 

 

5  SDown    6  ICU    7  OR    8  Txf    9  Death

 

NCode 1

 

 

 

     /     /     .   

 

 

NCode 2

NA

 

 

     /     /     .   

 

 

NCode 3

NA

 

 

     /     /     .   

 

 

NCode 4

NA

 

 

     /     /     .   

 

 

NCode 5

NA

 

 

     /     /     .   

 

 

Discharge Disp*

 

 

1  Home**    2  AMA    3  ACareF

 

 

 

 

4  InPtRehab    5  SkCare    6  ResFac

 

 

 

 

7  Expired

 

Facility Out***

NA

Unk

 

     /     /     /    

 

 

Hospital Days***

NA

 

 

     /     /    

(000  -  <1  day)

 

Expression***

NA

Unk

1DTH    2DPH    3ID    4I   *

 

Feeding***

NA

Unk

1DTH    2DPH    3ID    4I   *

 

Locomotion***

NA

Unk

1DTH    2DPH    3ID    4I   *

 

Rehab Potential***

NA

Unk

1  Poor    2  Fair    3  Good

 

Billed Charges

 

Unk

 

$

     /     /     /     /     /    

 

 

Primary Payment Source

 

Unk

A,  B,  C,  D,  E,  F,  G,  H,  I,  J*

 

 

*          See Instruction Book for table detail

**        Not applicable to Head and Spinal Cord Reporting

***      For Violent Injury Reporting will only be included if the patient had an in-patient stay

 

(Source:  Added at 22 Ill. Reg. 5047, effective March 10, 1998)