North Carolina Administrative Code (Last Updated: November 13, 2014) |
TITLE 10A. HEALTH AND HUMAN SERVICES |
CHAPTER 41. EPIDEMIOLOGY HEALTH |
SUBCHAPTER A. COMMUNICABLE DISEASE CONTROL |
10A NCAC 41A .0105. HOSPITAL EMERGENCY DEPARTMENT DATA REPORTING
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Hospitals, as defined in G.S. 130A-480(d), shall submit electronically to the Division of Public Health the following electronically available emergency department data elements for all emergency department visits:
(1) Patient record number or other unique identification number;
(2) Patient date of birth and age;
(3) Patient's sex;
(4) City of residence;
(5) County of residence;
(6) Five digit ZIP code;
(7) Alpha numeric patient control number assigned by the hospital for each record (the Visit Identification Number);
(8) Emergency department facility identification number;
(9) Projected payor source;
(10) Date and time of emergency department visit (first documented time);
(11) Mode of transport to the emergency department;
(12) PreMIS identification number, if transported by EMS;
(13) Chief complaint;
(14) Initial temperature reading and route;
(15) Initial systolic and initial diastolic blood pressure;
(16) Triage Notes (brief description of patient's/family's self-reported illness episode, including symptoms, duration of symptoms, and reasons for visit [in addition to Chief Complaint] as presented by the patient or family to the triage nurse upon arrival at the emergency department) – this element is optional;
(17) Initial emergency department acuity assessment;
(18) Coded cause of injury (ICD-9-CM, if injury related to diagnosis);
(19) Emergency department procedures, up to ten (CPT or ICD-9-CM or ICD-10-CM);
(20) Emergency department disposition;
(21) Emergency department disposition diagnosis description; and
(22) Emergency department disposition diagnosis codes, one primary and up to ten additional (ICD-9-CM or ICD-10-CM).
History Note: Authority G.S. 130A-480;
Eff. January 1, 2005.