Item. 1 Establishment identifier 2 Person Identifier 3 Date of injury. 4 Episode begin date 5 AROC Impairment Code 6 Admission ASIA score

Transcription

1 Please use the attached excel workbook to record additional data on your spinal cord The excel workbook (file) has two worksheets. The first is an information sheet The adjunct module has been designed to record ASIA scores (admission and All code sets for the adjunct data items are available from a dropdown list. Som The adjunct data set should be saved to your hard-drive/server with the followin AROC_SCI_adjunct_FacilityName.xls where Facility name is your facility na When submitting a copy of your facility s adjunct data set it should be saved to AROC_SCI_adjunct_FacilityName_yyyymmdd.xls - where Facility name is y The adjunct data set should be submitted to AROC quarterly via to aroc@ AROC SCI Item Number Item 1 Establishment identifier 2 Person Identifier 3 Date of injury 4 Episode begin date 5 AROC Impairment Code 6 Admission ASIA score 7 Discharge ASIA score 8 Admission level of injury

2 9 Discharge level of injury 10 Ventilator dependent at discharge? 11 Date clinically ready for discharge 12 Reason 1 for delayed discharge 13 Date clinically ready for discharge after delay 1

3 14 Reason 2 for delayed discharge 15 Date clinically ready for discharge after delay 2 16 Reason 3 for delayed discharge 17 Episode end date

4 Australian Rehabili Spinal Cord Injury Impairment s d patients. Collection of these additio instructing data managers and clinicians h discharge), level of injury (admission and d me fields require free text. It is necessary to ng name: ame have the following name: your facility name and yyyymmdd is the (same timing as the inpatient Item Format Item Code set Alphanumeric Alphanumeric DD/MM/YYYY DD/MM/YYYY Numeric Alphanumeric Alphanumeric Alphanumeric A B C D A B C D C1 C2 C3 C4 C5 C6 C7 C8 T1 T2 T3 T4 T5 T6

5 T7 T8 T9 T10 T11 T12 L1 L2 L3 L4 L5 S1 S2 S3 S4-S5 Alphanumeric C1 C2 C3 C4 C5 C6 C7 C8 T1 T2 T3 T4 T5 T6 T7 T8 T9 T10 T11 T12 L1 L2 L3 L4 L5 S1 S2 S3 S4-S5 Alphanumeric Yes No DD/MM/YYYY Alphanumeric DD/MM/YYYY

6 Alphanumeric DD/MM/YYYY Alphanumeric DD/MM/YYYY

7 itation Outcomes Centre (AROC) specific adjunct module to the AROC dataset onal data items was identified as clinically relevant through a series of impairment specific benchmarking worksho how to complete the data collection sheet. The second is the data collection sheet/proforma itself. discharge), ventilator dependency and additional discharge data. All in all, it comprises 17 data items. o enter some data for each episode that has already been entered into your inpatient data in order to link the records. ate this file was sent to AROC t and ambulatory data sets, however your inpatient and ambulatory data will still need to be submitted via AROC Online Services), Comments Facility Code Medical Record Number (MRN) Date the patient had their SCI Date admitted to rehabilitation ward or started rehabilitation program See Appendix A ASIA score at admission to rehabilitation program or rehabilitation unit. ASIA score at discharge from rehabilitation program or rehabilitation unit. Level of spinal cord injury admission to rehabilitation program or rehabilitation unit. If cauda equina, state in comment field. If unable to establish level of injury, state paraplegia or quadriplegia in the comment field.

8 Level of spinal cord injury at discharge from rehabilitation program or rehabilitation unit. If cauda equina, state in comment field. If unable to establish level of injury, state paraplegia or quadriplegia in the comment field. Record whether patient was ventilator dependent at discharge Record date patient was clinically ready for discharge Record reason for delayed discharge if date clinically ready for discharge is not the same as episode end date Record date patient was clinically ready for discharge after delay 1

9 Record reason for delayed discharge if date clinically ready for discharge after delay 1 is not the same as episode end date Record date patient was clinically ready for discharge after delay 2 Record reason for delayed discharge if date clinically ready for discharge after delay 2 is not the same as episode end date Date episode ended

10 ps. They have been identified by clinicians for the providers of brain injury and spinal cord injury rehab

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16 Establishment identifier Person identifier Date of Injury Episode begin date AROC Impairment Code Admission ASIA score A

17 Discharge ASIA score Admission level of injury Discharge level of injury B C1 S4 S5 Ventilator dependent at discharge? Date clinically ready for discharge

18 Reason 1 for delayed discharge Date clinically ready for discharge after delay 1 Reason 2 for delayed discharge Date clinically ready for discharge after delay 2

19 Reason 3 for delayed discharge Episode end date Comment

20 Appendix A - AROC Spinal Cord Injury Impairment Guidelines USE this group only if there is a spinal cord/ caudaequina dysfunction. Do NOT use this group for post spinal surgery, unless the surgery has resulted in dysfunction of the spinal cord/ caudaequina. A detailed coding guideline for patients with spinal cord injury, disease and damage is contained in the appendix to assist in the coding of patients. It is suggested that this be reviewed when considering patients with these conditions to ensure the most accurate code relevant for patient is used. Non-traumatic Spinal Cord Dysfunction USE this group for cases with quadriplegia/paresis and paraplegia/paresis of non-traumatic (i.e., medical or post-operative) origin. AROC Impairment Group SPINAL CORD DYSFUNCTION AROC Impairment Group Code Paraplegia, Incomplete Paraplegia, Complete Quadriplegia, Incomplete, C Quadriplegia, Incomplete, C Quadriplegia, Complete, C Quadriplegia, Complete, C Other Nontraumatic Spinal Cord Dysfunction Aetiologic Diagnosis Tuberculosis/ infective processes involving the vertebral column Neoplasm/ tumour of spinal column or spinal meninges, malignant or benign (includes secondary tumours) Neoplasm of other parts of nervous system, of unspecified nature Transverse myelitis Intraspinal or paraspinal abscess Dissection of aorta Aortic aneurysm, ruptured Spontaneous haematoma Spondylosis with myelopathy Spinal infarction Intervertebral disc disorder with myelopathy Spinal stenosis in cervical region (if deficits include weakness) Spinal stenosis, other than cervical (if deficit includes weakness) Late effects of spinal cord injury Pathological fracture with associated spinal cord dysfuncti An unavoidable/recognised surgical complication resulting spinal cord dysfunction following surgery for the above conditions Traumatic Spinal Cord Dysfunction USE this group for cases with quadriplegia/paresis and paraplegia/paresis secondary to trauma (accident/injury). AROC Impairment Group SPINAL CORD DYSFUNCTION AROC Impairment Group Code Paraplegia, Incomplete Paraplegia, Complete Quadriplegia, Incomplete, C Quadriplegia, Incomplete, C Quadriplegia, Aetiologic Diagnosis Fracture of vertebral column with spinal cord injury Spinal cord injury without evidence of spinal bone injury Spinal cord dysfunction resulting from surgical misadventure

21 Quadriplegia, Complete, C Quadriplegia, Complete, C Other Traumatic Spinal Cord Dysfunction

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