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Indiana Trauma Registry Training Materials

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This is material used in the training of hospitals that are required to record incidents of trauma using the Indiana Trauma Registry.

Index



Self Directed Powerpoint Presentations:

The following training sections are very detailed, step-by-step guides on how to complete an incident form in the Indiana Trauma Registry.

Training Presentation:


Module #1 - Entering a New Incident

Module #1 shows the user how to enter data into the trauma registry, including what can be found on which tab, usage of the action menu, and how to find entries that have been started in order to continue data entry. It is almost 33 minutes long.

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Self Directed Materials


Demographics

The demographics section is the first page of an incident form where the patient's medical record number, injury date and time, and basic information about the patient are entered, including: name, DOB, race, gender, and address.

Trauma Incident Form (Full Record with ICD-10)

Indiana Patient Registry Training - Demographics

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Injury

This section allows the capture of the location of the injury, cause of injury (using E-Codes), and any protective equipment that may or may not have been used by the patient during the incident.

Trauma Incident Form (Full Record with ICD-10)

Indiana Patient Registry Training - Injury

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Pre-Hospital

The pre-hospital section includes information as how the patient got to the hospital, barriers to caring for the patient, and EMS run sheet information including: dates and times of dispatch, arrival to scene, and departure from scene, as well as initial vital signs recorded by the EMS provider.

Trauma Incident Form (Full Record with ICD-10)

Indiana Patient Registry Training - Pre-Hospital

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Referring

The referring hospital section is only used if the patient was transferred from an initial hospital to another hospital.  If the patient was transferred and information was received from the initial hospital, the patient's vital signs, procedures performed, and medications administered while at the initial hospital can be captured here.

Trauma Incident Form (Full Record with ICD-10)

Indiana Patient Registry Training - Referring

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ED/Acute Care

The ED/Acute Care section allows the entry of the date and time the patient arrived and left the ED, Trauma Team Activation information, where the patient went after leaving the ED, and if transferred, where they were transferred to.

Trauma Incident Form (Full Record with ICD-10)

Indiana Patient Registry Training - ED and Acute Care

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Initial Assessment

The Initial Assessment section captures the initial vital signs in the ED, blood bank information, radiology information (such as CT scans and abdominal ultrasounds), and laboratory information (BAC and drug use).

Trauma Incident Form (Full Record with ICD-10)

Indiana Patient Registry Training - Initial Assessment

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Diagnosis

The patient's diagnosis codes are entered using both an ICD-9 code format, as well as an AIS code format.  Codes can be looked up using keywords or drop-down menus.  When AIS codes are entered, the ISS score is calculated.

Trauma Incident Form (Full Record with ICD-10)

Indiana Patient Registry Training - Diagnosis

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Co-Morbidity

If the patient has a comorbid condition, a condition from the national list can be chosen or a condition can be typed in.  Additional notes can also be made about the condition.

Trauma Incident Form (Full Record with ICD-10)

Indiana Patient Registry Training - Comorbidity

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Procedures

The procedures tab allows the capture of the procedures the patient had while in the hospital (ICD-9 code format), where the procedure was performed, the date and time the procedure was performed, and who performed the procedure.

Trauma Incident Form (Full Record with ICD-10)

Indiana Patient Registry Training - Procedures

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Complications/PI

The Complications/PI section is used for those facilities working on performance improvement measures and which want to document corrective actions the facility is taking.

Trauma Incident Form (Full Record with ICD-10)

Indiana Patient Registry Training - Complications and PI

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Outcome

The Outcome tab captures the date and time the patient was admitted and discharged from the hospital, where they were discharged to, how they paid for their hospital visit, and their feeding, independence,and motor scores.

Trauma Incident Form (Full Record with ICD-10)

Indiana Patient Registry Training - Outcome

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Additional Materials

Actions Menu



At the top of every incident is an actions drop-down menu.  This training explains the actions menu which includes how to validate a record, viewing a patient summary report, and adding peer review notes.

Indiana Patient Registry Training - Actions Menu

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Incident Information Box

This training explains the 'Incident Information' box located at the top of each incident on every tab.

Indiana Patient Registry Training - Incident Information Box

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Icon Manual

The icon manual is a quick reference tool that explains all of the icons used throughout the Indiana Trauma Registry.

Indiana Patient Registry Training - Icon Manual

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Report Writer

The Report Writer guide explains how to run the different reports in the Indiana Trauma Registry.

Indiana Patient Registry Training - Report Writer

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Contact Information

Registry Coordinator, Division of Trauma and Injury Prevention

Work:

Page last updated 1/4/2021

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