Identifying and Documenting Data Points in Hospital Events

By Michael Trelow, CSTR, CAISS

The Trauma Registry Professional must be familiar with each hospital event to accurately identify and document the correct data points. Since hospital events can change yearly, the Trauma Registry Professional must adapt to these changes.

Recognizing that everyone has a unique learning style, the National Trauma Data Standard, NTDS, documentation provides various methods for understanding. Whether you read the document directly or use an algorithm, the key is to find what works best for you. The 2024 Hospital Event Algorithm flow chart, available for download from AKI TEST, is a valuable resource for those who find algorithms helpful. For the 2025 NTDS, the algorithms are integrated into the documentation, catering to different learning styles.

When reviewing hospital events, it’s crucial to put in extra effort to identify specific conditions, such as Acute Kidney Injury. You’re vital in comprehending what you’re examining, and this might require broadening your knowledge by learning about factors like what defines an eGFR.

ACUTE KIDNEY INJURY EXAMPLE:

stages of chronic kidney disease
Understanding the language and structure of NTDS Hospital Event documentation is crucial for accurate data interpretation and reporting. The presence of “and/or” statements requires careful attention to ensure that the data is categorized correctly. Additionally, the flow of data within the algorithm can vary, highlighting the importance of thoroughly reviewing each document. Familiarity with these nuances is essential for maintaining the integrity of the data and supporting effective patient care outcomes.

The American College of Surgeons Trauma Quality Improvement Program (ACS TQIP) is crucial in enhancing patient care by collecting data on hospital events. This data is instrumental in identifying facilities with lower incidence rates, which can serve as benchmarks for others. By analyzing and adopting the strategies of these leading facilities, hospitals can work towards reducing their event rates, ultimately improving patient outcomes and elevating the standard of trauma care.

Want to enhance your trauma registry operations?

Contact Brundage Workforce Solutions today to learn how our expert services can support your hospital’s needs.

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