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1. on the same line with the level of consciousness on admission Enter unknown or unspecified LOC if appropriate If loss of consciousness is the only indicator of head injury terminology such as CHI meaning closed head injury traumatic brain injury TBI head injury or cranial trauma must be entered in order for Tri Code to code the LOC duration This is necessary as LOC information is coded only in the presence of head injury Tri Code needs this information to distinguish from LOC caused by other factors shock drug use etc All loss of consciousness information should be entered on one line Include loss of consciousness information for deaths if duration is greater than 24 hours Alabama Trauma Registry ATR Web Portal DI Trauma Registry Tri Code User Manual Penetrating Injuries e Ifa patient sustains both blunt and penetrating injuries enter all blunt injuries then all penetrating injuries e Indicate the cause in the first penetrating injury description e Tri Code assumes that all injury descriptions that follow it are open unless specified otherwise For example GSW to abdomen lac stomach fx femur In this case Tri Code assumes the GSW to be the cause of all subsequent injuries and codes the stomach lac and femur fx as open If the fx femur did not result from the GSW and is not an open fracture it must be either identified as closed or entered before the GSW entry for Tri Code to process it correctly Tri Code
2. 8 Rib He TA ES a nse einer eae a a RT EEE Tr ame 8 Vertebral Fractures Dislocations and Cord Injuries Disk Herniation with Nerve Root njury R dictlopathy ossis edna EREE 8 Fr tures with Dislocati nisirnnennn naa n E aa 9 Basilat Skull Soca cease sacrum cusecacesece ana vacances esta teacher 9 DDS eect nthe ie cea bse detest acca ead tata E EEEE 9 Wessel MUTES iaee eea E E EEE EEEE AEE EEEE EEEE 9 GST DaT o E mT A E E E E 9 Confusing Termihol g nessineniae rn re E A NNE 10 Descriptions with Double Meaning cccccceesceceseceeeceeeeeeseecaeceseeneeeenseecsaeeneenees 10 UptradeS onesten orere ce ERE AE E E E E TERE E R N 10 Non specific IUES sisisi irria Era Ea EE EERE EEE EER S 10 Additional Injury Description Entry Guidelines 0 ee eeceeeeeseceteeneeeneeeneeeneeeeenaes 11 NIAC OMS ASSUMP ONG x caccspsxsutnssiesusiny casticcucwsa henncaunnesnesescusiiapeiastesseeenecilucansiudoswetaes 11 2010 Digital Innovation Inc All Rights Reserved 1 Alabama Trauma Registry ATR Web Portal DI Trauma Registry Tri Code User Manual Tri Code Overview Tri Code is based on the Abbreviated Injury Scale AIS injury severity coding The injury severity score assigned by Tri Code is dependent on the injury description abstracted and entered into the Injury Narrative Tri Code provides consistent injury coding However if injuries are not appropriately documented in patient records or are not carefully abstracted inconsistenc
3. Alabama Trauma Registry ATR Web Portal digital innovation DI Trauma Registry Tri Code User Manual Hg O50 ecg oy eee eer ee nr ee eee ee ene ed ener rere eer reer iais 2 Why Cod with Fri Ode 7 aecvacessicuadevsdctecauesenctete renin see edness A iT maine 2 Usine Tri Golesi eire E EE ES REEE Eaa 3 Editing Existing Injury Nana VG s ccususvuesnrcosvesuuioessa assessed taghhncmsnaacsoctswmoivsncageatiss 4 Cotrecting Injury Narrative nieri naa oe eos 5 Abstracting Injury DEseri puns syicaccsssntsnavvaniindannsevseasnndecansntieedsianeasinnadacereetxcanntenernancdaGune 6 Coding Terminology as cdssnayss cspecswedsnsdnsbavesnccsiabeadutdoobenundtwatsuldaveayedecnasobdentanetencdsaldsiasviies 6 TC DOCS A A E E 6 ATIS Abbreviated Injury Scale sicesccnancccascessceewzerse craven seaivnnnteacncensseeoneannacdsonevaivanneontene 6 ISS Injury Severity SCOr ceciscenonesisa ar ERa a EE EN 6 RITS Revised Trauma Score eeii nea E E EAEE waa 6 Injury Description Entry and Specificity saicccsiscssissssvaedessiusdsdceadancennciuddsoevasdtnedustdsvedustss 6 Spacihg eor oera rea ir Ra EEr EER en uae ea ded ARE EA E eee 6 Usina NuUMDErS on ae ceccleaectaecaun agiriren araia aa ESAE REEERE EEEE E ERER EAEEREN ASERS 7 Use of Age in Injury Descriptions sser asinis rir k K a 7 Head Injuries and Loss of Consciousness LOC cccccsceceseceseeeeeeeseeeseeeeneeeeeeenaees 7 Penetrating INUIS eee ee meee ene sirere aeieea iaasa a irea naa eee eee eee aas ee
4. T include R O rule out possible or probable injuries unless you begin the line with e Enter the side of the injury whenever possible in many cases it will affect codes assigned Tri Code will process and code each injury description When appropriate it will upgrade severities due to the presence of other injuries The information on the screen will identify the ICD 9 CM code the AIS PREDOT code and severity score for each injury as well as those associated with upgrades Further data entry guidelines are provided in the following sections Spacing Spacing is very important to Tri Code e When using numbers and words together e g 2 cm always separate the number and word with at least one space Some other examples of this are 150 cc or 6 X 3 dimensions e The exception to this rule is the entry of multiple injuries For example if three scalp lacerations occurred it would be entered scalp lacs X3 This helps Tri Code distinguish between 6 X 3 by 3 and X3 times 3 e When stating percent use number and sign with no space between e g 15 2010 Digital Innovation Inc All Rights Reserved 6 Alabama Trauma Registry ATR Web Portal DI Trauma Registry Tri Code User Manual Using Numbers Numbers numerals should be entered rather than the word equivalent when describing degree of injury For example 2 X 3 cm lac scalp Centimeters cm or inches in only may be used to describe length and depth Centim
5. ebrum e When cerebrum is not entered Tri Code assumes the injury is to the scalp e Phalanx injuries must state finger or toe e Ventricle injuries must state head brain or chest heart e Septal injuries must state location Upgrades In the presence of other injuries and conditions ICD 9 CM and AIS PREDOT codes may change and the AIS severity scores for some injuries may be increased or decreased For example fx 5 left ribs tension pneumothorax LUL LML lung laceration In this case the severity of the pneumothorax is included in the severity score for the lung lacerations Therefore the severity assigned to the pneumothorax is 0 and no upgrade is given to the rib fractures Tri Code processes all injury descriptions and performs the appropriate upgrade Non specific Injuries The following are examples of non specific injury descriptions that Tri Code cannot process e multiple fractures e dislocated joint e multiple trauma e lacerations with bleeding vessels In order for Tri Code to process these descriptions the sites of the fractures and dislocations must be identified and the specific injuries resulting from the trauma must be stated The location of the lacerations and the names of the vessels must also be given 2010 Digital Innovation Inc All Rights Reserved 10 Alabama Trauma Registry ATR Web Portal DI Trauma Registry Tri Code User Manual Additional Injury Description Entry Guidelines The foll
6. eters cm2 or inches in2 squared should be used to describe area Cubic centimeters cc should be used to describe volume Only one description using numbers should be entered per line For example 1 cm lac of heart w 250 cc hemopericardium should be entered as follows 1 cm lac of heart 250 cc hemopericardium When there is more than one of the same injury e g multiple skin lacerations describe them using the following format scalp lacs X2 multiple scalp lacs If length and depth detail are not available again use numbers or multiple to describe more than one injury For example perforation of the jejunum X3 Use of Age in Injury Descriptions AIS scores for certain injury descriptions will change depending on patient age For these injuries enter the patient s age on the first line Enter the age using numbers and include years or months in the description Age may be included on the same line as the injury text only if no other numbers are used on that line Head Injuries and Loss of Consciousness LOC 2010 Digital Innovation Inc All Rights Reserved Each type of head injury must be entered on a separate line even though certain injuries are combined for ICD 9 CM coding For all head injured patients LOC duration should be included if known If LOC duration is not available indicate the patient s level of consciousness on admission If the patient is awake or lethargic on admission indicate prior LOC
7. icated or disclosed without the expressed written approval of Digital Innovation Inc Reasonable steps are to be taken to insure that no unauthorized persons have access to the Software Products and that all authorized persons having access to the Software Products refrain from any such disclosure duplication or reproduction except as authorized by Digital Innovation Inc Copyright 1998 2010 Digital Innovation Inc All Rights Reserved 2010 Digital Innovation Inc All Rights Reserved 12
8. ies will persist This lowers the reliability and credibility of analyses using that coding Users should obtain a copy of the most recent version of the AIS manual and review it carefully The information in that manual is not repeated here Why Code with Tri Code It is ranked as an expert ICD 9 and AIS coder It allows for fast accurate coding of injuries It converts simple textual injury descriptions to ICD 9 AIS and ISS scores It provides uniform coding for trending and outcome studies It allows for accurate comparisons of data across different datasets It provides a statistical way to accurately measure the severity of a patient s injuries 2010 Digital Innovation Inc All Rights Reserved Alabama Trauma Registry ATR Web Portal DI Trauma Registry Tri Code User Manual Using Tri Code Follow the steps below to use Tri Code 1 Enter injury descriptions into the Injury Narrative field For specific guidelines on abstracting refer to the Abstracting Injury Descriptions section Injury Narrative GSW to abdomen eee lac stomach fx femur AIS Version a AIS 90 r98 E RRS 2 Select the Tri Code button 3 The Anatomical Diagnoses information will auto populate ICD 9 Code Predot AIS Severity ISS Body Region 863 1 Injury to stomach open 544420 STOMACH LAC NFS 2 4 821 10 Fx femur unspecified part open 851800 FEMUR FX NFS 3 5 2010 Digital Innovation Inc All Rights Reserved A
9. labama Trauma Registry ATR Web Portal DI Trauma Registry Tri Code User Manual Editing Existing Injury Narrative To edit an existing Injury Narrative follow these steps 1 Edit the text in the Injury Narrative field In the example below first degree burn is added to the Injury Narrative Injury Narrative GSW to abdomen oe lac stomach atin fx femur first degree burn AIS Version 4 Ars 90 198 15S 14 TRISS 2 Select the Tri Code button 3 The Confirm Tri Code screen will open Select OK to confirm the changes Select Cancel to cancel the changes Continuing will delete existing codes Are you sure you want to continue 4 The Anatomical Diagnoses information will update ICD 9 Code Predot AIS Severity 18S Body Region 863 1 Injury to stomach open 544420 STOMACH LAC NFS 2 4 821 10 Fx femur unspecified part open 851800 FEMUR FX NFS 3 5 946 1 First degree burn of multiple specified sites 912002 BURNS 1ST DEGREE gt 1 YR OLD ANY TB 1 6 2010 Digital Innovation Inc All Rights Reserved 4 Alabama Trauma Registry ATR Web Portal DI Trauma Registry Tri Code User Manual Correcting Injury Narrative The Tri Code functionality will present users with warnings when incorrect data is entered In the example below stomach is spelled incorrectly Injury Narrative GSW to abdomen ane lac stomech fx femur AIS Version 4 AIS 90 r98 ISS i4 TRISS Tei Code_ When the user selects the Tri Code but
10. ndicating blood loss use volume entered on same line as vessel injury Crush Injuries e Crushed chest and crushed skull by AAAM definition are injury descriptions that usually occur in non survivors e Ifthe patient s injuries do not coincide with the definitions of crushed chest or crushed skull enter more specific anatomic injury descriptions 2010 Digital Innovation Inc All Rights Reserved 9 Alabama Trauma Registry ATR Web Portal DI Trauma Registry Tri Code User Manual Confusing Terminology e The use of certain words may result in incorrect coding by Tri Code e Above and below or the entry of two or more body locations in describing one injury should be avoided For example lac above r eye should be entered as lac r eyelid or lac r eyebrow or lac r forehead to indicate the specific location If entered as lac above r eye Tri Code will code it as a lacerated right eye which would probably not be what the user intended Similarly lac below lip would be coded by Tri Code as a lacerated lip when lacerated chin may be what the user actually meant SW RUQ below costal margin uses the term below and indicates RUQ as well as the costal margin For Tri Code to code this correctly be concise and enter SW RUQ Descriptions with Double Meaning e Certain injuries have different meanings when entered in different ways e Right parietal contusion can imply a contusion to the scalp or to the cer
11. nes Head injury and LOC information Bilateral fractures of the same bone Bilateral lung lacerations Multiple cerebral contusions specifying various locations Radius ulna fractures Tib fib fractures Tri Code Assumptions Frontal parietal occipital or temporal contusions are assumed to be to the scalp unless lobe or cerebral is indicated Internal carotid artery and vertebral artery injuries are assumed to be in the neck region unless intracranial is stated Optic nerve injuries are assumed to be intracranial unless intraorbital is stated Thoracic strain is assumed to be to the chest unless back or dorsal is indicated 2010 Digital Innovation Inc All Rights Reserved 11 Alabama Trauma Registry ATR Web Portal DI Trauma Registry Tri Code User Manual Proprietary Rights Notice The Web Portal and related materials including but not limited to this document and other written material provided by Digital Innovation Inc collectively Software Products constitute confidential and proprietary information of Digital Innovation Inc It is the responsibility of the user to comply with all applicable copyright laws The Software Products are to be maintained in confidence and not to be disclosed duplicated or otherwise reproduced directly or indirectly whole or in part or any materials relating thereto except as specifically authorized by Digital Innovation Inc No portions of this manual may be reproduced dupl
12. owing injuries must be entered on the same line in order to process them correctly Vertebral fx or fx DL with associated cord injury Bilateral hemo pneumothoracies Bilateral flail chest Bilateral SDH or EDH Injuries to uterus when pregnancy is involved must include trimester information on same line Disk herniation with accompanying nerve root injury radiculopathy Vessel injuries and blood loss Organ injuries and blood loss The following injuries must be entered on separate lines in order for Tri Code to process them correctly Right rib fractures must be entered on one line and left rib fractures must be entered on a different line Burns of different degrees must be entered on separate lines Enter first degree on one line second degree on a separate line and third degree on another line Basilar skull fractures must be entered on a separate line from fractures to the vault of the skull Two or more nerve injuries in same extremity must be entered on separate lines Nerve must be named for coding Fractures or joint injury with associated nerve injury must be stated on separate lines in order for all injuries to be coded and upgrades assigned Sacral or coccyx fractures with cauda equina injury must be listed on separate lines abdominal organ injuries with associated vessel injuries should be put on separate lines and the vessels should be named The following injuries can be entered on the same line or on separate li
13. ton the Tri Code Warnings Errors screen will open The warning message indicates that a substitution has been made stomach gt stomach Item Message MESSAGE 0 Line 2 Substitution made stomech gt stomach _Tri Code Ignore Accept Warnings Close Select the gnore Accept Warnings button to accept the substitution and automatically update the Injury Narrative 2010 Digital Innovation Inc All Rights Reserved 3 Alabama Trauma Registry ATR Web Portal DI Trauma Registry Tri Code User Manual Abstracting Injury Descriptions Coding Terminology ICD9 CM e Numerical method for tracking specific injuries e 1 to 1 correspondence between injury and code AIS Abbreviated Injury Scale e Measures anatomical severity of injury quantitatively and objectively ISS Injury Severity Score e Provides a single score for measuring overall severity based on AIS codes RTS Revised Trauma Score e Measures physiologic severity of injury based on vital signs Injury Description Entry and Specificity The following are general guidelines for entering the injury descriptions to Tri Code e Enter one injury description per line e Enter a complete injury description i e an anatomic structure type and extent of injury e Common abbreviations may be used e Include all details Tri Code cannot and will not assume information not entered e Enter all of a patient s injuries e Enter only definitive diagnoses DO NO
14. ual c4 body fx with central cord syndrome DL T9 with brown sequard syndrome e Disk herniation with nerve root injury radiculopathy must be stated on a single line Fractures with Dislocation e Fractures of all bones with dislocation or displacement must be entered on the same line in order to be processed correctly e Each bone must be listed separately Basilar Skull Fractures e Clinical signs of basilar skull fractures e g hemotympanum or CSF must be stated on the same line as the fracture For example temporal skull fx w hemotympanum Burns Burns may be coded many ways using ICD 9 CM However for Tri Code one option was chosen which is consistent with the manner in which AIS scores are assigned e Enter the percent of body area burned for each degree of burn e Spell out the degree of burn first second or third and use numbers for the percent of body area burned with no space between number and sign e g 10 e Enter each degree of burn on a separate line e See the diagram of nines in the AIS manual to determine percentage of body area burned If the percentage of burn is not included Tri Code will assume NFS not further specified e Indicate if burns occur on the face hand s or genitals e Indicate patient age if less than one year e Example 10 first degree burn 20 second degree burn of arms hands and legs Vessel Injuries e Describe vessel injuries as completely as possible e When i
15. will combine entrance wounds with underlying injuries Exit wounds should not be entered If entered Tri Code will not code them Enter GSW or SW only once with the entrance wound Do not enter it on every line of text Rib Fractures e Enter the side and number of ribs fractured e Use separate lines for right rib fractures and for left rib fractures e The numbers of the fractured ribs may be entered in parentheses This specificity is required for Tri Code to assign the appropriate AIS severity score e Ifa flail chest is present record the side s involved The specific ribs fractured do not need to be identified and will not be coded in the presence of a flail chest Correct ways to enter rib fractures are fx L rib assumes 1 OR fx 1 Lrib L for left fx 3 L ribs OR fx L ribs 3 4 5 fx 2 R ribs OR fx R ribs 6 7 Vertebral Fractures Dislocations and Cord Injuries Disk Herniation with Nerve Root Injury Radiculopathy e Numbers indicating the level of vertebral fractures dislocations or spinal cord injuries should be entered immediately following the letter indicating the level Enter all corresponding numbers on one line For example c3 5 fracture t4 5 dislocation e Spinal fractures and or dislocation subluxation with cord injury must be described on a single line For example 2010 Digital Innovation Inc All Rights Reserved 8 Alabama Trauma Registry ATR Web Portal DI Trauma Registry Tri Code User Man

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