10a ncac 41a .0105      Hospital Emergency Department Data Reporting

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;

Pursuant to G.S. 150B-21.3A, rule is necessary without substantive public interest Eff. January 9, 2018.