This is material used in the training of hospitals that are required to record incidents of trauma using the Indiana Trauma Registry.
Ramzi Nimry, Trauma System Performance Improvement Manager, with the Division of Trauma and Injury Prevention, narrates a step-by-step presentation on how to use the Indiana Trauma Registry.
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.
Additional Training Material:
Module #1 - Registry Setup
Module #1 introduces the user to how trauma is defined in Indiana, how to customize the user’s information, the facility’s information, workflow, and the use of facility defined questions. It is 23 minutes long.
Module #2 - Entering a New Incident
Module #2 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 27 and a half minutes long.
Module #3 - Report Writer Feature
Module #3 shows the user how to use the report writer function to explore data in the system through the use of canned reports, as well as the creation of transactional, analytical, and exploratory reports. It is 28 and a half minutes long.
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.
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.
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.
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.
This tab is not used in the Indiana Trauma Form.
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.
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).
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.
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.
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.
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.
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.
The user guide provides a step-by-step tool in how to get around the registry outside of entering incidents into the registry. It explains how to log in, changing user information, where to enter a new incident, how to look up incidents already entered, where to change information about a facility, how to set up favorite locations/services/performance improvement audits, set up facility defined questions, set up/modify registry users, and set up/modify patient care staff.
Refresher Material for Incident Form Completion
The refresher materials for incident form completion covers the key points when entering a new patient into the trauma registry. This is a great tool for those who need a refresher on entering data into the registry.
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.
Incident Information Box
This training explains the 'Incident Information' box located at the top of each incident on every tab.
The icon manual is a quick reference tool that explains all of the icons used throughout the Indiana Trauma Registry.
The Report Writer guide explains how to run the different reports in the Indiana Trauma Registry.
Trauma System Performance Improvement Manager, Division of Trauma and Injury Prevention