IBID Field List
This topic is for IBID
iBID Screens
Refer to the following iBID screens for detailed field information:
- IBID Record Type
- IBID Demography
- IBID Causation
- IBID Prevention
- IBID Referral
- IBID Admission
- IBID Burn Injury
- IBID Airway Injury
- IBID Resuscitation
- IBID Co-Existing Disorders
- IBID Scar Potential
- IBID Complications
- IBID Pre-Discharge
- IBID Discharge
- IBID Follow Up
Field List
This article is a list of IBID database fields. It contains descriptions and guidance on the fields, why they are present and how to use them.
Field Name | Field Description | Field Guidance | |
---|---|---|---|
=Demographics= | UnitID | Static ID for each contributing burn service. | |
Given Name | Patient's given forename | ||
Other Name | Patient's middle name | ||
Family Name | Patient's surname | ||
DateOfBirth | Date of birth | The data entered will be checked against an acceptable range of dates and reported as an error it otherwise. | |
Sex | Patient sex, if known | Necessary for the epidemiological analysis of injury causation | |
NHSNumber | NHS number | This is now an NHS data requirement | |
HospitalID | Hospital medical notes number | recording of the host hospital medical notes number is important for retrospective audit and data validation | |
Country | Country of Residence. | Value in this field affect the formatting & validation of the postcode field. | |
Postcode | First section of the patient's residence Postcode | The postcode of residence fields allow the geographical placement of the patient and thus the epidemiological analysis. | |
Postcode2 | Second section of the patient's residence Postcode | The postcode of residence fields allow the geographical placement of the patient and thus the epidemiological analysis. | |
Latititude | Geographical Latitude | Can be used in situations where the post code is not available | |
Longtitude | Geographical Longitude | Can be used in situations where the post code is not available | |
Pt_Address_1 | |||
Pt_Address_2 | |||
Pt_Address_District | |||
Pt_Address_City | |||
Pt_Telephone | |||
Pt_Mobile | |||
Vulnerable Person | Is the patient felt be vulnerable? | According to local policy and guidelines, if the patient falls into the description of vulnerable then this item should be checked. | |
NOK_Relationship | The named next of kin relationship to the patent | The next of kin is not always a relation to the patient, it could be a friend, social worker or neighbour. | |
NOK_Forename | First or given name of the named Next of kin | ||
NOK_Surname | Family name of next of kin | ||
NOK_Addr_1 | |||
NOK_Addr_2 | |||
NOK_Addr_District | |||
NOK_Addr_City | |||
NOK_Postcode | |||
NOK_Telephone | |||
NOK_Mobile | |||
GP code | A code issued by the Department of Health (DH) for practicing GP's in England and Wales. | The GP code can be found in the host hospital's Patient Administration or EPR system. | |
GPName | |||
GP_Telephone | |||
GP_Address | |||
Health Visitor_Name | |||
Health Visitor_Telephone | |||
CPN_Name | |||
CPN_Telephone | |||
SW_Name | |||
SW_Telephone | |||
Home Help_Name | |||
Home Help_Telephone | |||
Resident District | Area name of residence | ||
Living Circumstances | Living circumstances of the patient | Choose from the menu item which best describes the type of accommodation in which the patient lived prior to injury should be chosen. | |
SocioEconClass | Socio economic class of the patient or main earner if the patient is a non-worker | The menu item that best describes the patients socio-economic status should be chosen. The list used outcomes from the UK Office of National Statistics. | |
Occupation | Occupation of the patient | ||
EarnerOccupation | Occupation of the main earner in the family if the patient is a non-worker | ||
Age | Calculated field from the date of birth | Is calculated from the date of birth, or as entered separately this allows grouping of the individual into an appropriate age bracket and is essential to epidemiological analysis and mortality prediction | |
Height | Patient's height in metres | ||
Weight | Patient's weight in kilogrammes | ||
BodyMassIndex | Calculated field from the patient's height and weight | ||
Body Habitus | The overall body type of the patient. | The menu item that best describes the general body shape of the patient should be chosen. This will allow forms analysis to be done with the body mass index to indicate if this is revealed statistically to be a risk factor for a poor outcome following burn injury. | |
Record Type | Choose from the menu items which record type that best fits the reason the patient is being admitted. Explanation of the fields is below: | This field highlights whether the injury was an acute injury or part of the rehabilitation or reconstructive efforts. Different forms of analysis are performed based on this information. | |
Acute Major Injury Admission (resus&/or significant inhalation injury) AND Acute minor injury admission (not resus&/or inhalation) |
In the Record Reason fields in BIBID these were recorded as Acute Injury Admission | ||
Delayed new referral for admission of non-acute, non major burn (unhealed injury requiring treatment) injury older than 48 hours | In the Record Reason field in BIBID this was recorded as Post Acute Management | ||
Referral of acute minor injury requiring OP treatment (injury less than 48 hours) | In the Record Reason field in BIBID this was recorded as Acute Injury Assessment | ||
Delayed referral of minor OP non acute burn, non major unhealed injury requiring treatment (injury older than 48 hours) | New field to iBIDv2 | ||
Repatriation referral (from another burn service) | New field to iBIDv2 | ||
Complication management as part of on-going treatment | In the Record Reason field in BIBID this was recorded as Complication Management | ||
Planned re-admission as part of on-going treatment | In the Record Reason field in BIBID this was recorded as Planned Re-Admission | ||
Referral or admission for rehabilitation | In the Record Reason field in BIBID this was recorded as Rehabilitation | ||
Old burn injury requiring management (for scar management or reconstruction) | In the Record Reason field in BIBID this was recorded as Reconstruction | ||
Non burn or wound case requiring admission for burn team care | New field to iBIDv2 | ||
Non burn or wound case (admission of another specialty to the Burn Service) | New field to iBIDv2 | ||
TraumaNetworkID | Incremental automatic number given to each new entry | ||
Major Injury Event No | This field will only be completed in the event of a major incident where a different hospital number will be allocated to a patient. | ||
Em_Serv_Password | |||
DateOfInjury | Date of the injury which has initiated the referral | This field places the injury in time and is the basis of calculating any delay in referral and treatment | |
TimeOfInjury | Time of the injury which has initiated the referral | ||
CauseOfInjury | Free text field to provide a description of the injury circumstances | If the injury causation menus do not allow accurate characterisation of the injury, this text field allows a full description of the circumstances of the injury to be detailed. Analysis of this field allows improvement in the menu structures that describe the injury causations. | |
DaysPostInjury | Calculated field using Date of Injury | ||
Reason for admission | |||
FireBrigade | Were the fire brigade involved in the injuring incident? | ||
FDR1_No | Fire Brigade reference number | ||
Intentional Injury Suspected | Is the injury regarded as potentially nonaccidental or in potentially cause? | If it is suspected by the burn care team that the injury was intentionally caused by either the patient or another person, then this item should be checked. | |
Neglect Suspected | Is the injury regarded as potentially caused or contributed to by some form of neglect? | If it is suspected by the burn care team that the injury was caused or contributed to by some form of neglect on behalf of the patient or some other person, then this item should be checked. | |
Known to Social Services | Is the patient known to social services? | If it is established that patient is known to social services, then this item should be checked | |
Safeguarding Plan Subject | Is this patient subject to a safeguarding plan? | If it is established that patient is known to have a safeguarding plan in place, then this item should be checked | |
Referral to Social Services | |||
Outcome of Safeguarding Plan | Free text description of the outcome of safeguarding plan | ||
Locality | Pick the most suitable location of the incident | The menu item that identifies the most suitable description for the location of the injury and incident should be chosen. If the precise item is not available then this can be detailed in the available text box. | |
Locality_txt | Free text fields to enter further description of locality | ||
LivingSpace | Pick the most suitable area in the dwelling (if suitable) of the incident site | If the injury occurs in or around the home, or some other form of residence, then the menu item that best categorises the location where the injury took place should be chosen. | |
Space_txt | Free text fields to enter further details if known. | ||
Activity | Pick the most suitable activity the patient was engaged in at the time of the incident | The most appropriate characterisation of the activity undertaken at the time of injury needs to be picked from the menu. If complete accuracy is not possible the best menu item should be picked and the detail entered into the associated text box. | |
Activity_txt | Free text fields to enter further details if known | ||
Category | Pick the most suitable type of injury | The most appropriate menu item that characterises the type of injury should be chosen from the menu. Additional detail can be added to the associated text box. | |
Category_txt | Free text fields to enter further details if known. | ||
TypeOfInjury | Pick the most suitable type of injury | This categorisation of the injury allows epidemiological analysis and informs areas requiring preventative action. | |
Type_txt | Free text fields to enter further details if known. | ||
SourceOfInjury | Pick the source contributing most to the injury. | Choose the menu item that the best characterises the agent that contributed to be majority of the presenting injury. This may be difficult with complex injuries but in general terms the primary accelerant or thermal energy source should be chosen. | |
Source_txt | Free text fields to enter further details if known. | ||
None apply_Assoc | Did any of the associated causes contribute to the burn injury? | If none apply, check this box. | |
Vehicle fire | Was the injury caused by a vehicle fire? | ||
Residential fire | Was the injury caused by a fire in residential structure? | ||
Explosion | Did an explosion of any type occur as part of the incident? | ||
Entrapment | Was the casualty unable to escape the incident? | ||
Clothingfire | Was a clothing fire part of the mechanism of injury? | ||
Clothing Item | Were any of these clothing items involved in the event or the mechanism of injury? | If one of the clothing items in the menu was involved in the event of the mechanism injury then choose that item. This is an attempt to identify the number of injuries associated with these key items. | |
Bedclothesfire | Was a bed clothes fire part of the mechanism of injury? | ||
Immersion | Did the mechanism of injury involve immersion in a volume of fluid? | ||
Guardedappliance | Was an appliance with a guard part of the mechanism of injury? | This may include an open coal fire or gas fire with coal effect or indeed any form of heating device. | |
Unguardedappliance | Was an appliance without a guard part of the mechanism of injury? | This may include an open coal fire or gas fire with coal effect or indeed any form of heating device. | |
Unsafeappliance | Was an appliance deemed to be unsafe part of the mechanism of injury? | From the history it is apparent the appliance involved in the mechanism of injury was intrinsically unsafe for use in an unsafe manner, then this item should be checked. | |
None apply_Contrib | No contributing factors apply | Check this box if no contributing factors apply to the incident. | |
Illicit Drugs | Did the fact the casualty was abusing illicit drugs play a part in the mechanism of injury? | If this factor was involved in the circumstances that allowed the injury to occur then this item should be checked. | |
Alcohol | Did the fact the casualty was abusing alcohol play a part in the mechanism of injury? | ||
Smoking | Did the fact the casualty is a smoker play a part in the mechanism of injury? | ||
Learningdifficulty | Did the fact the casualty has a learning difficulty play a part in the mechanism of injury? | ||
Epilepsy | Did the fact the casualty have epilepsy play a part in the mechanism of injury? | ||
Carelessness | Did the fact the casualty was careless play a part in the mechanism of injury? | ||
Dementia | Did the fact the casualty has dementia play a part in the mechanism of injury? | ||
Motordisability | Did the fact the casualty has a motor disability play a part in the mechanism of injury? | ||
Sensorydisability | Did the fact the casualty has a sensory disability play a part in the mechanism of injury? | ||
Mental state | Did the mental state of the casualty play a part in the mechanism of injury? | ||
Supervision Lapse | Did lapse in supervision of the casualty play a part in the mechanism of injury? | ||
Nation_incident | Was the injury to this individual part of a major incident? | If the injury to this patient was part of a major incident, then this item should be checked. | |
PC_1_incident | First section of postcode of place of incident |
||
PC_2_incident | Second section of postcode of place of incident | ||
Latitude_incident | |||
Longitude_incident | |||
Incident | |||
Visited | |||
Contact | |||
Spoken English | |||
Mobility | |||
Dwelling | |||
Ownership | |||
First Aid | |||
Circumstances | |||
Appliance | |||
Appliance make | |||
Age of appliance | |||
Appliance acquired | |||
Ownership of appliance | |||
Instructions available | |||
Mother | |||
Father | |||
Siblings | |||
Child minder | |||
Grandparent | |||
Relative | |||
Friend | |||
other | |||
Iron type | |||
Cord type_I | |||
toaster type | |||
Cord type_T | |||
Slot number | |||
Kettle type | |||
Kettle design | |||
Cord type_K | |||
Material | |||
Position_K | |||
Cooker Type | |||
Heat indicator_C | |||
Lights on ring | |||
Guard fitted | |||
Standing | |||
Split level | |||
Ring arrangement | |||
Ring type | |||
Self lighting pilot | |||
Door type | |||
Door material | |||
Grill level | |||
Radiator type | |||
Mounting_R | |||
Thermostat | |||
Position_R | |||
Fire type | |||
Fire front | |||
Fixation | |||
Fire guard | |||
Boiler type | |||
Mounting_B | |||
Placement | |||
Bath type | |||
Hand rails_B | |||
Heat indicator_B | |||
Hot tap position | |||
TMV fitted_B | |||
TMV type_B | |||
Shower type | |||
Hand rails_S | |||
Heat indicator_S | |||
Hot water control | |||
TMV fitted_S | Was a thermo mixer valve fitted? | ||
TMV type_S | What type of thermo mixer valve was fitted? | ||
FirstAidGiven | Was First Aid provided? | Check this box if First Aid was provided. | |
FirstAidDelay | What was the delay time in minutes, providing any First Aid, if given? | ||
FirstAidType | What type of First Aid was administered, if any? | ||
First Aid comments | Free text field for details regarding First Aid. | ||
UKTARNID_Ref | The UK TARN record reference number | If the UK TARN record reference number is known it should be entered in this field. | |
Referred by | What is the name of the referring service provider? | ||
ReferralSite | What service or source did the referral come from? | That menu item the best describes the site from which the initial referral was received should be chosen. If any more accurate description is available that is not in the menu structure, this can be ended in the associated text box. | |
ReferralStaff | What is the name of person making the referral? | ||
HostReferralSite | What is the name of the referral source? | ||
Referrer Contact Number | |||
Referrer contact details | |||
ReferralDate | What date was the referral made? | This should be the first date at which contact was made with the burn service in order to make a referral rather than to ask for advice. | |
ReferralTime | What date was the referral made? | ||
ReferralNotes | Free text to record here any noteworthy characteristics of the referral. | ||
ReferralS_SD | What was the TBSA of the superficial and superficial dermal portion of the injury, as assessed by the referrer? | ||
ReferralDD_FT | What was the TBSA of the deep dermal and full thickness portion of the injury, as assessed by the referrer? | ||
ReferralTotal | This is a calcuated field using data from Referral S_SD and DD_FT fields, showing the total TBSA of the injury, as assessed by the referrer? | This value is often available from the copy of the referral notes sent with the patient but the referrer should always be asked to make this assessment and record it appropriately. | |
Treatment to date | Free text field to enter details of treatment given | ||
Decision Support | |||
CoDisorders | |||
Injury Mechanism | |||
Associated Injuries | |||
Delayed Healing | |||
Self care limitations | |||
Community care limitations | |||
Rehab limitations | |||
NBBB involved in referral | |||
NBBBLevel | What was the NBBB level of the casualty from the information provided by the referrer? | Choose the menu item that best describes the patient's level of monitoring dependency. A full description of these menu items are available from the National Burn Care Review document Appendix 3. | |
Initial Response | Was the referral once made accepted or refused? | All referrals once received should be recorded as either Accept or Refuse | |
Initial Action | Based on the initial response, what is the initial action to be? | Menu items available for this field are based on the option chosen in the Initial Response field, ie Accept or Refuse. | |
Outcome of Refusal | Free Text field | Record details of the outcome of the refusal if known. | |
TransportType | What type of transport was predominantly used in transfering the patient? | Choose the most suitable menu item that describes the mode of transfer. | |
Number of transfer journeys | |||
Reason for Transfer Delay | |||
Date first OR visit | Date the patient's first visit to the burns outreach service | ||
Where first seen | Where within the burn service was the patient first seen? | Choose the menu item that best describes the site of the initial assessment. | |
DNA Appt | Did the patient DNA their appointment? | ||
AssessmentDate | Date the injury was first assessed by the burn service? This could have been in A&E, Outreach, Out patients etc. | The assessment date can be the same as admission date if the patient is admitted. If the patient is assessed and not admitted the date of assessment may be the only contact point for the patient with the burn service. | |
AssessmentTime | Time of day the injury was first assessed by the burn service? | ||
Referral Justified | |||
Referral Justification | |||
Referral Accurate | |||
AdmissionDate | Date the patient was first admitted by the burn service? | This will often be the date of the first assessment, but not invariably so. This item should be filled if the patient is formally admitted into a bed within the burn ward. | |
AdmissionTime | Time of day the patient was first admitted by the burn service? | ||
InjToAdmDelay | A calculation in hours of the delay between injury and admission. | ||
Admitting Nurse | Name of the admitting nurse. | ||
AdmissionWard | Name of the ward the patient was admitted to. | ||
SeenByWho | Which member of staff made the initial assessment of injury severity? | ||
SeenDate | Which date was this assessment made? | ||
SeenTime | At what time of day was this assessment made? | ||
SeenByGrade | What is the grade of staff who first assessed the injury? | ||
SeenBySpec | What specialty is the first assessor from? | ||
AdmittingSpec | What is the admitting specialty for the patient? | ||
AdmittingCons | What is the name of the admitting Consultant for the patient? | ||
EyeOpening | GCS assessment score for eye opening. | ||
MotorResponse | GCS assessment score for motor response. | ||
VerbalResponse | GCS assessment score for verbal response. | ||
SedatedVent | At the time of GCS assessment, was the patient sedated or mechanically ventilated? | ||
GCScore | Calculation field of the total GCS. | ||
Admission Comments | Free text field for further admission details. | ||
Complications attrib to Transfer | Free text field | ||
CoreTemperature | What was the core temperature when first seen? | ||
PR | What was the pulse rate when first seen? | ||
RR | What was the respiratory rate when first seen? | ||
BPSystolic | What was the diastolic BP when first seen? | ||
BPDiastolic | What was the systolic BP when first seen? | ||
CapilRefill | What was the capillary refill rate when first seen? | ||
PulseOxymetry | Was pulse oximetry used when the patient was first seen? | ||
PulseOxymetryPerc | What was the pulse oximetry level when first seen? | ||
Pale | Does the patient exhibit these signs / symptoms? | ||
Sweating | Does the patient exhibit these signs / symptoms? | ||
Agitated / Restless | Does the patient exhibit these signs / symptoms? | ||
Central cyanosis | Does the patient exhibit these signs / symptoms? | ||
ConsultantSeenDate | On which date did the consultant first see the patient? | This should be the date on which the patient was first seen by any Consultant that forms part of the burn care multidisciplinary team. | |
ConsultantSeenTime | At which time of day did the consultant first see the patient? | This should be the time at which the patient was first seen by any Consultant that forms part of the burn care multidisciplinary team. | |
Consultant_Code | |||
Blast injury suspected | Is blast injury suspected as part of the mechanism of injury? | ||
No Inhal S_S | No signs or symptoms of inhalation injury present. | ||
Nostrilburnssooting | Does the patient exhibit this sign / symptom of inhalation injury? | ||
Mouthburnssooting | Does the patient exhibit this sign / symptom of inhalation injury? | ||
Stainedsputum | Does the patient exhibit this sign / symptom of inhalation injury? | ||
Hoarsevoice | Does the patient exhibit this sign / symptom of inhalation injury? | ||
Uvulaoedema | Does the patient exhibit this sign / symptom of inhalation injury? | ||
Epiglottisoedema | Does the patient exhibit this sign / symptom of inhalation injury? | ||
Vocalcordoedema | Does the patient exhibit this sign / symptom of inhalation injury? | ||
Dyspnoea | Does the patient exhibit this sign / symptom of inhalation injury? | ||
Stridor | Does the patient exhibit this sign / symptom of inhalation injury? | ||
Lungfieldscrackles | Does the patient exhibit this sign / symptom of inhalation injury? | ||
Lungfieldswheezes | Does the patient exhibit this sign / symptom of inhalation injury? | ||
Bronchchangesupperairway | Does the patient exhibit this sign / symptom of inhalation injury? | ||
UA_erythema | Does the patient exhibit this sign / symptom of inhalation injury? | ||
UA_bleeding | Does the patient exhibit this sign / symptom of inhalation injury? | ||
UA_pallor | Does the patient exhibit this sign / symptom of inhalation injury? | ||
UA_ulceration | Does the patient exhibit this sign / symptom of inhalation injury? | ||
UA_oedema | Does the patient exhibit this sign / symptom of inhalation injury? | ||
UA_contamination | Does the patient exhibit this sign / symptom of inhalation injury? | ||
Bronchchangescarina | Does the patient exhibit this sign / symptom of inhalation injury? | ||
C_erythema | Does the patient exhibit this sign / symptom of inhalation injury? | ||
C_bleeding | Does the patient exhibit this sign / symptom of inhalation injury? | ||
C_pallor | Does the patient exhibit this sign / symptom of inhalation injury? | ||
C_ulceration | Does the patient exhibit this sign / symptom of inhalation injury? | ||
C_oedema | Does the patient exhibit this sign / symptom of inhalation injury? | ||
C_contamination | Does the patient exhibit this sign / symptom of inhalation injury? | ||
Bronchchangesbronchi | Does the patient exhibit this sign / symptom of inhalation injury? | ||
B_erythema | Does the patient exhibit this sign / symptom of inhalation injury? | ||
B_bleeding | Does the patient exhibit this sign / symptom of inhalation injury? | ||
B_pallor | Does the patient exhibit this sign / symptom of inhalation injury? | ||
B_ulceration | Does the patient exhibit this sign / symptom of inhalation injury? | ||
B_oedema | Does the patient exhibit this sign / symptom of inhalation injury? | ||
B_contamination | Does the patient exhibit this sign / symptom of inhalation injury? | ||
Intubated | Was the patient intubated (other than for surgery) during their period of care? | This is an indication as to whether the patient required ventilatory support (other than for surgery) at any time during their admission. | |
IntubatedWhere | Site where first intubation took place following injury. | The most appropriate menu item should be chosen. If intubation occurred at a different site this should be recorded in the associated text box. | |
Intubation Reason | |||
IntubatedDate | Date on which the patient was first intubated following injury | ||
IntubatedTime | Time of day at which the patient was first intubated following injury | ||
Was intubation needed | |||
InhaleSeverity | Overall assessment of the severity of inhalation injury? | This is a clinical assessment as to the degree of airway injury. It will be expected that mild injuries would not require intubation but possibly close observation. Both moderate and severe injuries would require intubation and mechanical ventilation. Deciding between the moderate and severe can be done on the basis of bronchoscopy and the degree of airway contamination or damage. | |
BloodGasDate_ED | What is the date of the first arterial blood gas sample taken in the Emergency Department? | ||
BloodGasTime_ED | Time of day of the first arterial blood gas sample taken in the Emergency Department? | ||
pOxygen_ED | Value of the partial pressure of oxygen (kPA) from the first arterial blood gas sample in the Emergency Department. | ||
pCarbonDioxide_ED | Value of the partial pressure of carbon dioxide (kPA) from the first arterial blood gas sample in the Emergency Department. | ||
Base Excess_ED | |||
Lactate_ED | |||
pH_ED | Value of the pH from the first arterial blood gas sample in the Emergency Department. | ||
FiOxy_ED | Value of the inspired oxygen level at the time of the first arterial blood gas sample in the Emergency Department. | ||
pCO_ED | Percentage of carbon monoxide from the first arterial blood gas sample in the Emergency Department. | ||
MetHb | |||
CyanateBldDate | Date of the first cyanide blood level taken in the Emergency Department. | ||
CyanateBldTime | Time of day of the first cyanide blood level taken in the Emergency Department. | ||
pHCN | Blood cyanide level (if available) from the first sample taken. | ||
pThiocyanate | Blood thiocyanate level (if available) from the first sample taken in the Emergency Department. | ||
BloodGasDate_BS | Date of the first arterial blood gas sample taken in the burn service. | ||
BloodGasTime_BS | Time of day of the first arterial blood gas sample taken in the burn service. | ||
pOxygen_BS | Value of the partial pressure of oxygen (kPA) from the first arterial blood gas sample in the burn service. | ||
pCarbonDioxide_BS | Value of the partial pressure of carbon dioxide (kPA) from the first arterial blood gas sample in the burn service. | ||
Base Excess_BS | Base excess is defined as the amount of strong acid that must be added to each litre of fully oxygenated blood to return the pH to 7.40 at a temperature of 37°C and a pCO2 of 40 mmHg (5.3 kPa). | Enter the value of Base excess. This value is usually reported as a concentration in units of mEq/L, with positive numbers indicating an excess of base and negative a deficit. | |
Lactate_BS | |||
pH_BS | Value of the pH from the first arterial blood gas sample in the burn service. | ||
FiOxy_BS | Percentage of the inspired oxygen level at the time of the first arterial blood gas sample in the burn service. | ||
pCO_BS | Percentage of carbon monoxide from the first arterial blood gas sample in the burn service | ||
Prim and Sec Survey results | Free text field | ||
PSU_SFSD_BSA | What was the TBSA of the superficial and superficial dermal portion of the injury, as assessed at the burn service? | This characterises the area of skin injury that is, on assessment felt to be capable of spontaneous recovery. Recognition is made that the depth of injury may change with time. | |
PSU_FTDD_BSA | What was the TBSA of the deep dermal and full thickness portion of the injury, as assessed at the burn service? | This characterises the area of skin injury that is, on assessment felt not capable of spontaneous recovery and is likely to require resurfacing or a protracted period of dressings. | |
PSU_TOTAL_BSA | This is a calculated field using data entered in the SF/SD BSA and FT/DD BSA giving a TBSA of the injury, as assessed at the burn service? | This is a total portion of the body involved in injury, expressed as a percentage. | |
OtherAnatomInj | Free text to list all other (non-burn) injuries sustained. | ||
Face | Was this area of the body involved by the burn injury? | ||
Face_Dth | The depth of injury that occurred in this part of the body. | This menu list details the depth to which the injury extended in this part of the body. The item that describes the deepest injury recorded should be chosen. | |
Neck | Was this area of the body involved by the burn injury? | ||
Neck_Dth | The depth of injury that occurred in this part of the body. | This menu list details the depth to which the injury extended in this part of the body. The item that describes the deepest injury recorded should be chosen. | |
Scalp | Was this area of the body involved by the burn injury? | ||
Scalp_Dth | The depth of injury that occurred in this part of the body. | This menu list details the depth to which the injury extended in this part of the body. The item that describes the deepest injury recorded should be chosen. | |
AntChest | Was this area of the body involved by the burn injury? | ||
AntChest_Dth | The depth of injury that occurred in this part of the body. | This menu list details the depth to which the injury extended in this part of the body. The item that describes the deepest injury recorded should be chosen. | |
PostChest | Was this area of the body involved by the burn injury? | ||
PostChest_Dth | The depth of injury that occurred in this part of the body. | This menu list details the depth to which the injury extended in this part of the body. The item that describes the deepest injury recorded should be chosen. | |
RtShoulder | Was this area of the body involved by the burn injury? | ||
RtShoulder_Dth | the depth of injury that occurred in this part of the body. | This menu list details the depth to which the injury extended in this part of the body. The item that describes the deepest injury recorded should be chosen. | |
LtShoulder | Was this area of the body involved by the burn injury? | ||
LtShoulder_Dth | The depth of injury that occurred in this part of the body. | this menu list details the depth to which the injury extended in this part of the body. The item that describes the deepest injury recorded should be chosen. | |
RtUpperArm | Was this area of the body involved by the burn injury? | ||
RtUpperArm_Dth | The depth of injury that occurred in this part of the body. | This menu list details the depth to which the injury extended in this part of the body. The item that describes the deepest injury recorded should be chosen. | |
LtUpperArm | Was this area of the body involved by the burn injury? | ||
LtUpperArm_Dth | The depth of injury that occurred in this part of the body. |
This menu list details the depth to which the injury extended in this part of the body. The item that describes the deepest injury recorded should be chosen. | |
RtForearm | Was this area of the body involved by the burn injury? | ||
RtForeArm_Dth | The depth of injury that occurred in this part of the body. | This menu list details the depth to which the injury extended in this part of the body. The item that describes the deepest injury recorded should be chosen. | |
LtForearm | Was this area of the body involved by the burn injury? | ||
LtForeArm_Dth | The depth of injury that occurred in this part of the body. | This menu list details the depth to which the injury extended in this part of the body. The item that describes the deepest injury recorded should be chosen. | |
RtHandDorsal | Was this area of the body involved by the burn injury? | ||
RtHandDorsal_Dth | The depth of injury that occurred in this part of the body. | This menu list details the depth to which the injury extended in this part of the body. The item that describes the deepest injury recorded should be chosen. | |
LtHandDorsal | Was this area of the body involved by the burn injury? | ||
LtHandDorsal_Dth | The depth of injury that occurred in this part of the body. | This menu list details the depth to which the injury extended in this part of the body. The item that describes the deepest injury recorded should be chosen. | |
RtHandPalmer | Was this area of the body involved by the burn injury? | ||
RtHandPalmar_Dth | The depth of injury that occurred in this part of the body. | This menu list details the depth to which the injury extended in this part of the body. The item that describes the deepest injury recorded should be chosen. | |
LtHandPalmer | Was this area of the body involved by the burn injury? | ||
LtHandPalmar_Dth | The depth of injury that occurred in this part of the body. | This menu list details the depth to which the injury extended in this part of the body. The item that describes the deepest injury recorded should be chosen. | |
Abdomen | Was this area of the body involved by the burn injury? | ||
Abdomen_Dth | The depth of injury that occurred in this part of the body. | This menu list details the depth to which the injury extended in this part of the body. The item that describes the deepest injury recorded should be chosen. | |
Lumbarback | Was this area of the body involved by the burn injury? | ||
LumbarBack_Dth | The depth of injury that occurred in this part of the body. | This menu list details the depth to which the injury extended in this part of the body. The item that describes the deepest injury recorded should be chosen. | |
Perineum | Was this area of the body involved by the burn injury? | ||
Perineum_Dth | The depth of injury that occurred in this part of the body. | This menu list details the depth to which the injury extended in this part of the body. The item that describes the deepest injury recorded should be chosen. | |
Buttocks | Was this area of the body involved by the burn injury? | ||
Buttocks_Dth | The depth of injury that occurred in this part of the body. | This menu list details the depth to which the injury extended in this part of the body. The item that describes the deepest injury recorded should be chosen. | |
RtThigh | Was this area of the body involved by the burn injury? | ||
RtThigh_Dth | The depth of injury that occurred in this part of the body. | This menu list details the depth to which the injury extended in this part of the body. The item that describes the deepest injury recorded should be chosen. | |
LtThigh | Was this area of the body involved by the burn injury? | ||
LtThigh_Dth | The depth of injury that occurred in this part of the body. | This menu list details the depth to which the injury extended in this part of the body. The item that describes the deepest injury recorded should be chosen. | |
RtLowerLeg | Was this area of the body involved by the burn injury? | ||
RtLowerLeg_Dth | The depth of injury that occurred in this part of the body. | This menu list details the depth to which the injury extended in this part of the body. The item that describes the deepest injury recorded should be chosen. | |
LtLowerLeg | Was this area of the body involved by the burn injury? | ||
LtLowerLeg_Dth | The depth of injury that occurred in this part of the body. | This menu list details the depth to which the injury extended in this part of the body. The item that describes the deepest injury recorded should be chosen. | |
RtFootDorsal | Was this area of the body involved by the burn injury? | ||
RtFootDorsal_Dth | The depth of injury that occurred in this part of the body. | This menu list details the depth to which the injury extended in this part of the body. The item that describes the deepest injury recorded should be chosen. | |
LtFootDorsal | Was this area of the body involved by the burn injury? | ||
LtFootDorsal_Dth | The depth of injury that occurred in this part of the body. | This menu list details the depth to which the injury extended in this part of the body. The item that describes the deepest injury recorded should be chosen. | |
RtFootSole | Was this area of the body involved by the burn injury? | ||
RtFootSole_Dth | The depth of injury that occurred in this part of the body. | This menu list details the depth to which the injury extended in this part of the body. The item that describes the deepest injury recorded should be chosen. | |
LtFootSole | Was this area of the body involved by the burn injury? | ||
LtFootSole_Dth | The depth of injury that occurred in this part of the body. | This menu list details the depth to which the injury extended in this part of the body. The item that describes the deepest injury recorded should be chosen. | |
Contamination | The degree of wound contamination evident on presentation. | The menu item that best describes the degree of contamination of wounds at the time of presentation should be chosen. | |
Non burn trauma | Was non-burn trauma evident at the time of presentation? | ||
ISS value | What was the ISS at the time of assessment? | If known, the injury severity score should be recorded in this field. | |
Injury Details | Free text field | ||
IVI established | |||
antibiotic given | |||
Possible NAI | |||
XR of injury | |||
XR of C spine | |||
CXR | |||
XR of pelvis | |||
Photo | Was a photographic record of the injury taken at the time of first assessment/admission? | ||
Specific Facial Notes | Free text field | ||
Dominant Side | |||
Specific Hand Notes | Free text field | ||
Page8Update | This field is an automatic updated field when items in Page 8 are entered or altered. | ||
FormalResusc | Was formal fluid resuscitation for the burn injury initiated? | ||
ResuscStartDate | What was the commencement date for the fluid resuscitation? | ||
ResuscStartTime | What was the commencement time of day for the fluid resuscitation? | ||
PrincResuscFluid | What was the principle type of fluid used in the fluid resuscitation? | ||
ComfortCareOnly | Was comfort care alone initiated for the patient? | Ticking this field indicates that during the period of initial assessment and resuscitation a decision was made that the injury was not survivable and the patient was to receive comfort care only, with the acknowledgement that active resuscitation and treatment would be futile. | |
ComfortCareStarted | Date that comfort care was started. | ||
None used in Resusc | None of the following procedures / tests / forms of therapy were provided during the resuscitation period (initial 24-36 hours)? | ||
Neckescharotomies | Was this procedure / test / form of therapy provided during the resuscitation period (initial 24-36 hours)? | ||
Chestescharotomies | Was this procedure / test / form of therapy provided during the resuscitation period (initial 24-36 hours)? | ||
Limbescharotomies | Was this procedure / test / form of therapy provided during the resuscitation period (initial 24-36 hours)? | ||
Urinecatheter | Was this procedure / test / form of therapy provided during the resuscitation period (initial 24-36 hours)? | ||
Oxygen | Was this procedure / test / form of therapy provided during the resuscitation period (initial 24-36 hours)? | ||
Bloodgases | Was this procedure / test / form of therapy provided during the resuscitation period (initial 24-36 hours)? | ||
Pulseoxymeter | Was this procedure / test / form of therapy provided during the resuscitation period (initial 24-36 hours)? | ||
Centralline | Was this procedure / test / form of therapy provided during the resuscitation period (initial 24-36 hours)? | ||
Urineosmolalities | Was this procedure / test / form of therapy provided during the resuscitation period (initial 24-36 hours)? | ||
Serumosmolalities | Was this procedure / test / form of therapy provided during the resuscitation period (initial 24-36 hours)? | ||
Arterialline | Was this procedure / test / form of therapy provided during the resuscitation period (initial 24-36 hours)? | ||
Swan-Ganz | Was this procedure / test / form of therapy provided during the resuscitation period (initial 24-36 hours)? | ||
Laryngoscopy | Was this procedure / test / form of therapy provided during the resuscitation period (initial 24-36 hours)? | ||
Bronchoscopy | Was this procedure / test / form of therapy provided during the resuscitation period (initial 24-36 hours)? | ||
Cricothyroidotomy | Was this procedure / test / form of therapy provided during the resuscitation period (initial 24-36 hours)? | ||
Tracheostomy | Was this procedure / test / form of therapy provided during the resuscitation period (initial 24-36 hours)? | ||
SelectiveGITdecon | Was this procedure / test / form of therapy provided during the resuscitation period (initial 24-36 hours)? | ||
CN antidote date | the date on which a specific cyanide antidote was given. | ||
CN antidote time | The time at which a specific cyanide antidote was given. | ||
Volume of resusc fluid given in first 24hrs post injury | Record amount of resuscitation fluid given in first 24 hr period following injury. | ||
Volume of urine from the first 24hrs post injury | Record amount of urine passed in the first 24 hrs post injury. | ||
Mean mls_Kg_perc | |||
No complications of Resusc | No complications occurred during the resuscitation period (initial 24-36 hours)? | ||
Compartment syndrome_brain | This complication occurred during the resuscitation period (initial 24-36 hours)? | ||
Compartment syndrome_optic | This complication occurred during the resuscitation period (initial 24-36 hours)? | ||
Compartment syndrome_abdo | This complication occurred during the resuscitation period (initial 24-36 hours)? | ||
Compartment syndrome_limb | This complication occurred during the resuscitation period (initial 24-36 hours)? | ||
hyponatraemia | This complication occurred during the resuscitation period (initial 24-36 hours)? | ||
non-vent pulm oedema req vent | This complication occurred during the resuscitation period (initial 24-36 hours)? | ||
non-vent airway oedema req vent | This complication occurred during the resuscitation period (initial 24-36 hours)? | ||
Myoglobinuria severity | |||
P_F_ratio | |||
Page9Update | This field is an automatic updated field when items in the page are entered or altered. | ||
No EXDIS | The patient did not have any existing conditions prior to injury and referral? | ||
EXDIS_NIDDM | Did the patient have this condition prior to injury and referral? | ||
EXDIS_IDDM | Did the patient have this condition prior to injury and referral? | ||
EXDIS_Epilepsy | Did the patient have this condition prior to injury and referral? | ||
EXDIS_Asthma | Did the patient have this condition prior to injury and referral? | ||
EXDIS_Bronchiolitis | Did the patient have this condition prior to injury and referral? | ||
EXDIS_URTI | Did the patient have this condition prior to injury and referral? | ||
EXDIS_UTI | Did the patient have this condition prior to injury and referral? | ||
EXDIS_Nonspecificviralillness | Did the patient have this condition prior to injury and referral? | ||
EXDIS_Failure to thrive | Did the patient have this condition prior to injury and referral? | ||
EXDIS_COAD | Did the patient have this condition prior to injury and referral? | ||
EXDIS_Emphysema | Did the patient have this condition prior to injury and referral? | ||
EXDIS_PreadmissionMRBacteria | Did the patient have this condition prior to injury and referral? | ||
EXDIS_Periphvasculardisease | Did the patient have this condition prior to injury and referral? | ||
EXDIS_Ischaemicheartdisease | Did the patient have this condition prior to injury and referral? | ||
EXDIS_PastMI | Did the patient have this condition prior to injury and referral? | ||
EXDIS_Hypertension | Did the patient have this condition prior to injury and referral? | ||
EXDIS_CardiacFailure | Did the patient have this condition prior to injury and referral? | ||
EXDIS_congenital heart dis | Did the patient have this condition prior to injury and referral? | ||
EXDIS_Heart Valve disorder | Did the patient have this condition prior to injury and referral? | ||
EXDIS_Cardiac dysrhythmia | Did the patient have this condition prior to injury and referral? | ||
EXDIS_Neoplasm | Did the patient have this condition prior to injury and referral? | ||
EXDIS_Metastatic Disease | Did the patient have this condition prior to injury and referral? | ||
EXDIS_Alcoholabuse | Did the patient have this condition prior to injury and referral? | ||
EXDIS_SubstanceabuseIV | Did the patient have this condition prior to injury and referral? | ||
EXDIS_Substanceabuseother | Did the patient have this condition prior to injury and referral? | ||
EXDIS_Psychiatricdisorder | Did the patient have this condition prior to injury and referral? | ||
EXDIS_Depression | Did the patient have this condition prior to injury and referral? | ||
EXDIS_PTSD | Did the patient have this condition prior to injury and referral? | ||
EXDIS_Anxiety | Did the patient have this condition prior to injury and referral? | ||
EXDIS_Personalitydisorder | Did the patient have this condition prior to injury and referral? | ||
EXDIS_Mania | Did the patient have this condition prior to injury and referral? | ||
EXDIS_Schizophrenia | Did the patient have this condition prior to injury and referral? | ||
EXDIS_Self harm | Did the patient have this condition prior to injury and referral? | ||
EXDIS_ADHD | Did the patient have this condition prior to injury and referral? | ||
EXDIS_Eating Disorder | Did the patient have this condition prior to injury and referral? | ||
EXDIS_Learningdifficulty | Did the patient have this condition prior to injury and referral? | ||
EXDIS_Dementia | Did the patient have this condition prior to injury and referral? | ||
EXDIS_PastCVA | Did the patient have this condition prior to injury and referral? | ||
EXDIS_Hemiplegia | Did the patient have this condition prior to injury and referral? | ||
EXDIS_PastDVT | Did the patient have this condition prior to injury and referral? | ||
EXDIS_Poorhearingordeafness | Did the patient have this condition prior to injury and referral? | ||
EXDIS_Pooreyesightorblind | Did the patient have this condition prior to injury and referral? | ||
EXDIS_Hepaticdysfunction_Mild | Did the patient have this condition prior to injury and referral? | ||
EXDIS_Hepaticdysfunction_Mod_Sev | Did the patient have this condition prior to injury and referral? | ||
EXDIS_Renaldysfunction | Did the patient have this condition prior to injury and referral? | ||
EXDIS_Cerebral Palsy | Did the patient have this condition prior to injury and referral? | ||
EXDIS_Paraplegia | Did the patient have this condition prior to injury and referral? | ||
EXDIS_Spina Bifida | Did the patient have this condition prior to injury and referral? | ||
EXDIS_Motordisabilityimmobility | Did the patient have this condition prior to injury and referral? | ||
EXDIS_Sensorydisability | Did the patient have this condition prior to injury and referral? | ||
EXDIS_MultipleSclerosis | Did the patient have this condition prior to injury and referral? | ||
EXDIS_Pregnancy1sttrimester | Did the patient have this condition prior to injury and referral? | ||
EXDIS_Pregnancy2ndtrimester | Did the patient have this condition prior to injury and referral? | ||
EXDIS_Pregnancy3rdtrimester | Did the patient have this condition prior to injury and referral? | ||
EXDIS_HepB | Did the patient have this condition prior to injury and referral? | ||
EXDIS_HepC | Did the patient have this condition prior to injury and referral? | ||
EXDIS_HIV | Did the patient have this condition prior to injury and referral? | ||
EXDIS_AIDS | Did the patient have this condition prior to injury and referral? | ||
EXDIS_Anaemia | Did the patient have this condition prior to injury and referral? | ||
EXDIS_Clotting Disorder | Did the patient have this condition prior to injury and referral? | ||
EXDIS_Immunosuppression | Did the patient have this condition prior to injury and referral? | ||
EXDIS_Leukaemia_Lymphoma | Did the patient have this condition prior to injury and referral? | ||
DisorderComments | Any comments about disorders not indicated amongst the preceding fields, or requiring further explanation and detail | ||
Tetanus Status | |||
ASAGradePreInj | The ASA Grade of the patient pre-injury, as an indication of overall fitness | ||
Pre_injury Child Psychosocial Score | |||
Pre_injury Adult Psychosocial Score | |||
Comprehension | |||
History of non-compliance | |||
Psychosocial comments | Free text field | ||
Page10Update | This field is an automatic updated field when items in the page are entered or altered. | ||
Race | Racial skin and colouration type | ||
Skin type | |||
Acne | |||
Any autoimmune disease | |||
Connective tissue disease | |||
Rheumatoid Arthritis | |||
SLE | |||
Systemic Sclerosis | |||
Dupuytrens | |||
Lung fibrotic disease | |||
Hyperthyroid disease | |||
Hypothyroid disease | |||
Uterine fibroid | |||
Peptic ulceration | |||
OC Pill years | |||
Number of pregnancies | |||
Date of last delivery | |||
Sun lamp use | |||
Episodes of sun burn in last 10yrs | |||
Sun burn when | |||
Areas of sun burn | |||
NRS Admission Nutrition Risk Score | |||
Dietary History | |||
Balanced diet | |||
Takes food supplements/vitamins | |||
Able to prepare meals | |||
Meals on wheels | |||
Wears dentures | |||
Well fitting dentures | |||
Weight steady in last year | |||
Tamoxifen | |||
Hormone Replacement Therapy | |||
Aspirin | |||
Warfarin | |||
Inhaled steroids | |||
Oral steroids | |||
Retinoids | |||
NSAIDs | |||
Immunosuppressives | |||
Other medication | |||
Allergies | |||
Examples of past scars | |||
Family history of aberrant scarring | |||
Past surgery for scars | |||
Past use of pressure for scars | |||
Past use of silicone for scars | |||
Past use of triamcinolone for scars | |||
Acrylic casts for scars | |||
Radiotherapy for scars | |||
Other scar treatments | |||
SmokerDay | Number of cigarettes (or equivalent) the patient smokes per day? | ||
CohabitWithSmoker | Does the patient co-habit with a regular smoker? | ||
Years a smoker | The number of years the patient has been a smoker. | ||
Smoking Comments | Comments concerning the patient smoking habit. | ||
Alcohol/week | The number of units of alcohol the patient drinks per week. | ||
Alcohol Use | The typical pattern of alcohol use the patient engages in. | The menu item that best describes the pattern of alcohol use patient engages in should be chosen. | |
Page11Update | This field is an automatic updated field when items in the page are entered or altered. | ||
No Complics | No complications occurred during their period of care? | ||
OverwhelmingWoundInfection | Did the patient suffer this condition during their period of care? | ||
MyocardialInfarction | Did the patient suffer this condition during their period of care? | ||
Pancreatitis | Did the patient suffer this condition during their period of care? | ||
DVT | Did the patient suffer this condition during their period of care? | ||
PulmonaryEmbolism | Did the patient suffer this condition during their period of care? | ||
CVA | Did the patient suffer this condition during their period of care? | ||
Toxicshocklikeillness | Did the patient suffer this condition during their period of care? | ||
Peripheral neuropathy | Did the patient suffer this condition during their period of care? | ||
Encephalopathy | Did the patient suffer this condition during their period of care? | ||
Ectopiccalcification | Did the patient suffer this condition during their period of care? | ||
Respiratoryfailure | Did the patient suffer this condition during their period of care? | ||
Renalfailure | Did the patient suffer this condition during their period of care? | ||
Hepaticfailure | Did the patient suffer this condition during their period of care? | ||
Cardiacfailure | Did the patient suffer this condition during their period of care? | ||
Multiorganfailure | Did the patient suffer this condition during their period of care? | ||
Pneumonia | Did the patient suffer this condition during their period of care? | ||
DIC | Did the patient suffer this condition during their period of care? | ||
Septicaemia | Did the patient suffer this condition during their period of care? | ||
ARDS | Did the patient suffer this condition during their period of care? | ||
GIBleed | Did the patient suffer this condition during their period of care? | ||
Smallbowelileus | Did the patient suffer this condition during their period of care? | ||
Pseudo-obstruction | Did the patient suffer this condition during their period of care? | ||
ComplicComments | Free text area to record any additional complicatoins not listed in the preceding fields or where additional information and detail is required | ||
Page12Update | This field is an automatic updated field when items in the page are entered or altered. | ||
ADL assessment | |||
Home visit | |||
Stairs assessment | |||
Pressure garments | |||
Splints | |||
Home equipment | |||
Walking aids | |||
Rehab Ready Date | The date on which the patient is ready for discharge to a rehabilitation service | This date should indicate when the degree of recovery and state of wound dressings are such, that the patient could be cared for within any form of rehabilitation service. It indicates the point at which wound management and recovery from acute injury is no longer the treatment priority. | |
ReadyForDiscDate | First date on which the burn care team felt the patient was ready for discharge as an in patient from the burn service | This date should indicate when the degree of recovery and state of wound dressings is such, that the patient could be cared for away from a hospital or rehabilition ward setting. It indicates when the patient is fit enough to continue recovering in a typical home environment. | |
DischDelayedBy | Reason for the patient not being discharged on the date deemed to be ready and appropriate | If the patient is unable to leave the burn ward then click the menu item that most appropriately describes primary reason. | |
Burns outreach team | Tick box if this services in required after discharge. | ||
Burns psychologist | Tick box if this services in required after discharge. | ||
Burns Physio_OT | Tick box if this services in required after discharge. | ||
Burns garment service | Tick box if this services in required after discharge. | ||
District Nurses | Tick box if this services in required after discharge. | ||
Community rehab | Tick box if this services in required after discharge. | ||
GP Practice Nurse | Tick box if this services in required after discharge. | ||
Community paed Nurse | Tick box if this services in required after discharge. | ||
Health Visitor | Tick box if this services in required after discharge. | ||
Arranged carers | Tick box if this services in required after discharge. | ||
Informal help | Tick box if this services in required after discharge. | ||
Home help | Tick box if this services in required after discharge. | ||
Meal on wheels | Tick box if this services in required after discharge. | ||
Social Worker | Tick box if this services in required after discharge. | ||
Community drug team | Tick box if this services in required after discharge. | ||
Community Alcohol team | Tick box if this services in required after discharge. | ||
Key worker | Tick box if this services in required after discharge. | ||
Psychiatrist | Tick box if this services in required after discharge. | ||
CPN | Tick box if this services in required after discharge. | ||
Psychologist | Tick box if this services in required after discharge. | ||
Discharge Comments | Free text field | ||
LOS to Date | Calculated field using data entered in the admission date field | ||
Page13Update | This field is an automatic updated field when items in the page are entered or altered. | ||
DischOrDeathDate | Date of which the patient was discharged from care as an in patient or death occurred | This is the date that the patient leaves the burn ward with no plans made for their imminent return. | |
DischOrDeathTime | Time of day at which the patient was discharged from in- patient care or time death occurred | ||
Death | Did the patient die during the period of in patient care? | This field should be checked for all patients who die while an in-patient within the burn service. | |
Discharge Nurse | |||
DischargeDest | The intended destination of the patient following discharge from in-patient care | The most appropriate menu item should be chosen but if additional more accurate information is available they should be entered into the associated text box. | |
DischargeWeight | Enter the discharge weight of the patient at the time of discharge | ||
WeightLoss | A calcuation field, indicating the percentage weight loss over the period of acute phase care in comparison to the admission weight | ||
DischDressing | Free text field to record the type and extent of dressings in place at the time of the patient's discharge as an in patient | ||
Discharge Information Given | Free text field | ||
Page14Update | This field is an automatic updated field when items in the page are entered or altered. | ||
COD_OverwhelmingWoundInfection | Was this condition a contributor to death? | ||
COD_Respiratoryfailure | Was this condition a contributor to death? | ||
COD_Renalfailure | Was this condition a contributor to death? | ||
COD_Hepaticfailure | Was this condition a contributor to death? | ||
COD_Pancreatitis | Was this condition a contributor to death? | ||
COD_Cardiacfailure | Was this condition a contributor to death? | ||
COD_MyocardialInfarction | Was this condition a contributor to death? | ||
COD_Multiorganfailure | Was this condition a contributor to death? | ||
COD_Pneumonia | Was this condition a contributor to death? | ||
COD_DVT | Was this condition a contributor to death? | ||
COD_PulmonaryEmbolism | Was this condition a contributor to death? | ||
COD_CVA | Was this condition a contributor to death? | ||
COD_Toxicshocklikeillness | Was this condition a contributor to death? | ||
COD_DIC | Was this condition a contributor to death? | ||
COD_Septicaemia | Was this condition a contributor to death? | ||
COD_ARDS | Was this condition a contributor to death? | ||
COD_GIBleed | Was this condition a contributor to death? | ||
COD_Bowel infarction | Was this condition a contributor to death? | ||
COD_Bowel perforation | Was this condition a contributor to death? | ||
COD_Smallbowelileus | Was this condition a contributor to death? | ||
COD_Pseudoobstruction | Was this condition a contributor to death? | ||
COD_Encephalopathy | Was this condition a contributor to death? | ||
COD_Intraoperativedeath | Did the patient die during an operative procedure? | ||
PostMortem | Was a post mortem examination carried out by a pathologist? | ||
OtherCausesofDeath | Free text field to record any other contributors to death not recorded by the preceding fields | ||
Page15Update | This field is an automatic updated field when items in the page are entered or altered. | ||
GeneralComments | Free text field for recording of any additional detail concerning the overall care of the patient | ||
FollowUpWhere | Free text field to record the primary site for initiation of post discharge follow up | ||
FollowUpDate | The date of first follow up appointment was to occur following discharge as an in patient | ||
FollowUpTime | The time of the day of first follow up appointment was to occurr following discahrge as an in patient | ||
ReturnWork_EducationDate | The date on which the patient returned to work or full-time education. | ||
Disch from Service | The date on which the patient was formally discharged from follow up by the burn care service. | ||
Date died after ward Discharge | |||
Cause of Death after ward Discharge | Free text field to enter details of cause of death post ward discharge. | ||
Page16Update | This field is an automatic updated field when items in the page are entered or altered. | ||
Copy Record | |||
Problem Record | |||
Problem Record Comments | |||
ProbRecOK | |||
Audit Case | |||
Research Case | |||
PC_all | |||
PC_area | |||
PC_district | |||
PC_sector | |||
Age_Int | |||
Age_Grpv1 | |||
Age_Grpv2 | |||
Group_Age1 | |||
Group_Age2 | |||
Group_Age3 | |||
TRNID_Yr | |||
Fin_Yr | |||
Fin_Qrt | |||
Mth | |||
Injury_Week | |||
Injury_Day | |||
Injury_ID | |||
Burn | |||
AssocFactors | |||
ContribFactors | |||
AcuteInjury | |||
Refusal | |||
Admission | |||
Inj_Ref_When | |||
Inj_Assm_When | |||
Ref_Assm_When | |||
Inj_Adm_When | |||
Ref_Adm_When | |||
Assm_Adm_When | |||
Delay | |||
InhalSymptoms | |||
Inhalation | |||
ICUAdmission | |||
OnVentDate | |||
ICUAdmDate | |||
ICUAdmTime | |||
Delta_Adm_CC | |||
Delta_Adm_vent | |||
TracheostomyDate | |||
OffVentDate | |||
ICUDischarge | |||
LosVentilated | |||
Max Org Support | |||
Max Organ Support Sum | |||
BRS days | |||
ARS days | |||
BCVS days | |||
ACVS days | |||
RS days | |||
GIS days | |||
LS days | |||
DS days | |||
NS days | |||
BW days | |||
HDU days | |||
ICU days | |||
LosICU | |||
PSU_BSA_INT | |||
BSA_Grp | |||
PSU_BSA_DP_INT | |||
DP_BSA_Grp | |||
BurnAreas_HH | |||
BurnAreas_Body | |||
BurnAreas_Legs | |||
BurnAreas_Total | |||
Ref_PSU_TBSA_percent | |||
ResuscProcedures | |||
EXDIS_Resus | |||
EXDIS_Complic | |||
EXDIS_Psyc | |||
EXDIS_Minor | |||
EXDIS_SIG | |||
EXDIS_Score | |||
FeedStartDate | |||
FirstOpDate | |||
LastOpDate | |||
InjToFirstOp | |||
TotalGA | |||
TotalGraftingOps | |||
Total Tx Tm | |||
COMPLIC_Moderate | |||
COMPLIC_Infectv | |||
COMPLIC_Severe | |||
COMPLIC_Total | |||
LosDelayedDisch | |||
TotalLos | |||
Adj_LOS | |||
Adj_LOS_Grp | |||
LOS_TBSA | |||
Adj_bw_LOS | |||
Adj_br_LOS | |||
COD_Infectv | |||
COD_Other | |||
COD_Total | |||
Adm_Disch_TARN | |||
Severity_DefB | |||
BC_UK_2010 | |||
BullScore | |||
BauxIndex | |||
Abbr BIS Score | |||
Outcome | |||
InjToHealDays | |||
InjToWkEdDays | |||
InjToServDiscDays | |||
Information_Group | |||
Dep_TraumaNetworkID | creates unique dep reference number | ||
Date_Time_Now | |||
Dep_When | |||
DepDate | |||
Day post acute injury | days post latest acute injury | ||
Status | A description of the status of the patient on the day in question. | The most suitable menu item should be chosen the described the status of the patient on this particular day and date | |
Location | A description of where the patient is being cared for. | The menu item describes the environment in which the patient is being cared for on this particular day and date should be chosen. | |
Bed Number | The bed number within the Burns Ward that is allocated to this patient | The menu item that identifies the bed in which the patients being cared for should be chosen | |
Shift | The nursing shift on which the dependency of the patient is assessed. | The menu item that describes the nursing shift on which the dependency the patient is assessed should be chosen stop | |
Off Ward | A description of where the patient is if they are not on the Burns Ward | With the patient is often Burns Ward at the time of dependency assessment for whatever reason then the most appropriate menu item should be chosen that describes why stop | |
Ward Attender for | Is the patient on the Burns Ward there has a warder tender on this day only? | If the patient is on the wall as a warder tender feel should be checked to indicate there will be no further dependency records unless the patient is subsequently admitted. | |
Monitoring Requirement | The the monitoring requirements of the patient on this date. | The menu item that best describes the patient's level of monitoring dependency should be chosen. A full description of these menu items is available from the national burn care review document appendix 3. | |
Procedure Complexity | The complexity level of procedures undertaken for the patient on this date. | The menu item that best describes the level of input provided to the patient should be chosen. the level of input is indicated in the menu items and is a proxy for staff time used in this way. | |
Psychosocial Support | The degree of the psychosocial support provided to the patient or visitors. | The menu item that best describes the level of input provided to the patient should be chosen. the level of input is indicated in the menu items and is a proxy for staff time used in this way. | |
ADL Achievement | The level of support the patient provided by burn care staff to fulfil the activities of daily living on this date. | The menu item that best describes the level of input provided to the patient should be chosen. the level of input is indicated in the menu items and is a proxy for staff time used in this way. | |
Mobility Limitation | The degree of mobility limitation experienced by the patient on this date. | The menu item that best describes the level of input provided to the patient should be chosen. the level of input is indicated in the menu items and is a proxy for staff time used in this way. | |
No Phys Therapy | No physical therapy was available on this date. | ||
Therapy Support | The degree of physical therapy support provides that the patient on this date will stop | The menu item that best describes the level of input provided to the patient should be chosen. the level of input is indicated in the menu items and is a proxy for staff time used in this way. | |
Treatment Complexity | The degree of complexity of care provided by the physical therapy staff on this date stop | The menu item that best describes the level of input provided to the patient should be chosen. the level of input is indicated in the menu items and is a proxy for staff time used in this way. | |
Basic care and support needs | The basic care and support requirements for the patient on this date. | The menu item that best describes the level of input provided to the patient should be chosen. this forms part of the rehabilitation complexity school and is a proxy of the staff time utilised in caring for the patient on this date. | |
Skilled nursing needs | The specialist nurse care requirements of the patient on this date. | The menu item that best describes the level of input provided to the patient should be chosen. this forms part of the rehabilitation complexity school and is a proxy of the staff time utilised in caring for the patient on this date. | |
Therapy intervention | The physical therapy requirements of the patient on this date will. | The menu item that best describes the level of input provided to the patient should be chosen. this forms part of the rehabilitation complexity school and is a proxy of the staff time utilised in caring for the patient on this date. | |
Medical intervention | The degree of medical support and intervention required by the patient on this date. | The menu item that best describes the level of input provided to the patient should be chosen. this forms part of the rehabilitation complexity school and is a proxy of the staff time utilised in caring for the patient on this date. | |
Current Status | Free text field to enter details of current status | ||
Treatment_Plan | Free text field to enter treatment plan for the day | ||
Other events text | Free text field to record any further events for that day | ||
Worst MEWS Score | the highest score for the medical early warnings score recordedon this date. | ||
Oral_Nasal ET Tube | is the patient supported with this form of therapy? | this item should be checked if the patient is receiving this form of support or therapy. | |
Surgical Trachy | is the patient supported with this form of therapy? | this item should be checked if the patient is receiving this form of support or therapy. | |
Percutaneous Trachy | is the patient supported with this form of therapy? | this item should be checked if the patient is receiving this form of support or therapy. | |
Mini Trachy | is the patient supported with this form of therapy? | this item should be checked if the patient is receiving this form of support or therapy. | |
Facemask/Trach mask/Nasal specs | is the patient supported with this form of therapy? | ||
CPAP Mask | is the patient supported with this form of therapy? | ||
Air spontaneously | is the patient supported with this form of therapy? | ||
B_under 2hourly physio or suction | is the patient supported with this form of therapy? | ||
Nebulised Adjuncts | is the patient supported with this form of therapy? | ||
Sputum Appearance | a description of any sputum samples. | from sputum samples provided by expectoration for particularly airway suction, click the menu item that best describes the material. | |
under 50pc O2 Breathing spont | is the patient supported with this form of therapy? | ||
B_over 50pc O2 Breathing spont | is the patient supported with this form of therapy? | ||
B_ CPAP via mask | is the patient supported with this form of therapy? | ||
A_CPAP via ETT/Trachy | is the patient supported with this form of therapy? | ||
B_Vision via mask | is the patient supported with this form of therapy? | ||
A_BIPAP/ASB/SIMV via ETT/Trachy | is the patient supported with this form of therapy? | ||
A_HFJV/HFOV | is the patient supported with this form of therapy? | ||
Hayek oscillator | is the patient supported with this form of therapy? | ||
B_Was patient ventilated on HDU | is the patient supported with this form of therapy? | ||
Proned | is the patient supported with this form of therapy? | ||
Turned back to supine | is the patient supported with this form of therapy? | ||
B_Recent extubation under 24hrs | As the patient recently been extubated? | If the patient has been it is debated within the last 24 hours then this item should be checked. | |
B_Close observation/apnoea risk | Is the patient supported with this form of therapy? | ||
A_ECMO | Is the patient supported with this form of therapy? | ||
Nitric oxide | Is the patient supported with this form of therapy? | ||
Pulmonary artery catheter | Is the patient supported with this form of therapy? | ||
Bronchoscopic investigation | Is the patient supported with this form of therapy? | ||
Lavage_Adjuncts | Is the patient supported with this form of therapy? | ||
Induced hypothermia | Is the patient supported with this form of therapy? | ||
Endoscopy | Is the patient supported with this form of therapy? | ||
Variceal tamponade | Is the patient supported with this form of therapy? | ||
Jugular venous monitoring | Is the patient supported with this form of therapy? | ||
Lumbar puncture | Is the patient supported with this form of therapy? | ||
A_Vasocative drugs_multiple | Is the patient supported with this form of therapy? | ||
B_Vasoactive drug_single | Is the patient supported with this form of therapy? | ||
B_Arterial line_sampling/monitoring | Is the patient supported with this form of therapy? | ||
B_CVP line_monitoring/drug delivery | Is the patient supported with this form of therapy? | ||
B_Hypovolaemic_circ instability | Is the patient supported with this form of therapy? | ||
B_Anti arrythmic drug_cont infusion | Is the patient supported with this form of therapy? | ||
A_Cardiac output_invasive | Is the patient supported with this form of therapy? | ||
B_Cardiac output_non-invasive | Is the patient supported with this form of therapy? | ||
A_IA Balloon pump/VAD | Is the patient supported with this form of therapy? | ||
A_Temporary cardiac pacemaker | Is the patient supported with this form of therapy? | ||
A_Post cardiac arrest stabilisation | Is the patient supported with this form of therapy? | ||
Xigris Drotrecogin Alfa | Is the patient supported with this form of therapy? | ||
Chronic Dialysis 3 mths | Is the patient supported with this form of therapy? | ||
Drug controlled only | Is the patient supported with this form of therapy? | ||
A_Intermittent haemodialysis | Is the patient supported with this form of therapy? | ||
A_Veno venous haemofiltration | Is the patient supported with this form of therapy? | ||
A_Peritoneal dialysis | Is the patient supported with this form of therapy? | ||
A_Parental feeding | Is the patient supported with this form of therapy? | ||
A_Enteral feeding | Is the patient supported with this form of therapy? | ||
Bowel management system | Is the patient supported with this form of therapy? | ||
A_Charcoal haemoperfusion | Is the patient supported with this form of therapy? | ||
A_MARS | Is the patient supported with this form of therapy? | ||
A_Major burns_over 30pc | Is the patient supported with this form of therapy? | ||
A_Major exfoliation_over 30pc | Is the patient supported with this form of therapy? | ||
A_Major rashes_over 30pc | Is the patient supported with this form of therapy? | ||
A_Multiple trauma dressings | Is the patient supported with this form of therapy? | ||
A_Open abdomen dressings | Is the patient supported with this form of therapy? | ||
Other complex dressings_over 1hr per day | Is the patient supported with this form of therapy? | ||
A_CNS Depression prejudicial to airway_obstructing | Is the patient supported with this form of therapy? | ||
CNS monitoring by clinical assessment | Is the patient supported with this form of therapy? | ||
A_CNS monitoring_invasive/ICP | Is the patient supported with this form of therapy? | ||
Non Invasive monitoring_BIS/EEG | Is the patient supported with this form of therapy? | ||
A_Severe agitation/Fits | Is the patient supported with this form of therapy? | ||
Cerebral function monitoring | Is the patient supported with this form of therapy? | ||
Observation only_neuro | Is the patient supported with this form of therapy? | ||
Time bed manager contacted | |||
Time bed allocated by bed manager | |||
Reason for delay if 6hrs difference | |||
Acute lung injury | Did the patient suffer this condition during their period of care? | ||
CVS Instability | Did the patient suffer this condition during their period of care? | ||
Renal tertiary failure | Did the patient suffer this condition during their period of care? | ||
Barotrauma | Did the patient suffer this condition during their period of care? | ||
Coagulopathy | Did the patient suffer this condition during their period of care? | ||
Hepatic tertiary failure | Did the patient suffer this condition during their period of care? | ||
Thrombocytopenia | Did the patient suffer this condition during their period of care? | ||
CNS | |||
Donated organs | |||
NRS_Nutrition Risk Score | |||
Dep_Weight | |||
Time feeding tube placed | |||
Type of feeding tube | |||
Gastrostomy | |||
Achieved target feeding rate | |||
Bowel Management tube | |||
Nutrition Comments | |||
Theatre visit | |||
Formal sedation on ward with Anaesthetist | |||
TimeInto Tx | |||
TimeOutOfTx | |||
Time in Theatre | |||
Escharotomies | |||
Donored | |||
Debrided | |||
Grafted | |||
Operator_Name | |||
Operating Grade | |||
Operating Grade Code | |||
Supervisor_Name | |||
Supervising Grade | |||
Supervising Grade Code | |||
Operative Detail | |||
Complex scan CT MRI etc | |||
Chest X-ray | |||
Units of blood inc operative use | |||
Units of FFP inc operative use | |||
Units of Platelets inc operative use | |||
Units of HAS inc operative use | |||
Nursed in a single cubicle | |||
Critical care transfer | |||
Psychology input | |||
Dietician input | |||
SALT input | |||
Ext Medical review | |||
Pain Team_Anaesthetic input | |||
Skin Substitute_1 | |||
TBSA Skin Sub_1 | |||
Skin Substitute_2 | |||
TBSA Skin Sub_2 | |||
Skin Substitute_3 | |||
TBSA Skin Sub_3 | |||
Donor_Site Load | |||
SFSD_Load | |||
DDFT_Load | |||
Graft Failure evident | |||
Large skin area dressings | |||
95percent_Healed | |||
100percent_Healed | |||
MR Bact Contamination | |||
MR Bact Septicaemia | |||
Non_MR Bact Septiciaemia | |||
Fungal Contamination | |||
Fungal Septicaemia | |||
StrepA Contamination | |||
StrepA Septicaemia | |||
Pseudomonas Contamination | |||
Pseudomonas Septicaemia | |||
Discharge to Rehab ready | |||
Discharge to Residence ready | |||
Discharge Delayed by | |||
Reason Discharge not possible | |||
Attended | |||
DNAd | |||
Rearranged | |||
Surgeon Assessment | |||
Sx_grade | |||
SxTmComm | |||
SxFUp | |||
Listed | |||
SxDisch | |||
Nurse Assessment | |||
Nurse_grade | |||
NurseTmComm | |||
NurseFUp | |||
NurseDisch | |||
Therapy Assessment | |||
Therapist_grade | |||
TherapistTmComm | |||
TherapistFUp | |||
TherapistDisch | |||
Psychologist Assessment | |||
Psychologist_grade | |||
PsychTmComm | |||
PsychFUp | |||
PsychDisch | |||
Pressure garment Tec assessment | |||
PressureTec_grade | |||
PressTecTmComm | |||
PressTecFUp | |||
Other Assessment | |||
Other_grade | |||
OtherTmComm | |||
Referral to Dermatology | |||
Referral to Cosmetic Camouflage | |||
Referral to Psychiatrist | |||
PREM | |||
PROM | |||
Compliance | |||
Adherence | |||
Lability | |||
Motivation | |||
Biomedical | |||
Employment | |||
Finance | |||
PsycSoc_Sex | |||
Psychiatric | |||
PedsQL Family Impact Module | |||
PedsQL Parent Report | |||
PedsQL Child Report | |||
CRIES-8 | |||
Satisfaction with Appearance | |||
Abilities | |||
Hand Function | |||
Work | |||
Body Image | |||
Affect | |||
Interpersonal | |||
Sexuality | |||
Heat Sensitivity | |||
Treatment Regimens | |||
BSHS_B Total Score | |||
Activity1 | |||
Activity1sc | |||
Activity2 | |||
Activity2sc | |||
Activity3 | |||
Activity3sc | |||
PSFS_pc | |||
Scar Site | |||
Vascularity | |||
Pigmentation | |||
Thickness | |||
Relief | |||
Pliability | |||
Surface Area | |||
Obs_Scale | |||
Obs_Overall | |||
Pain | |||
Itch | |||
Colour | |||
Stiffness | |||
Thickness_2 | |||
Irregularity | |||
Pt_Scale | |||
Pt_Overall | |||
Impr_Self Care | |||
Impr_Musculoskeletal | |||
Actv_Self Care | |||
Actv_Musculoskeletal | |||
ParticR_Score | |||
Distress_Wellbeing_Score | |||
FA4B_Score | |||
Pain Overall Lowest | Record of the lowest pain level recorded. | This field should record the lowest pain level recorded by the patient in the last 24 hours using the visual analogue scale. | |
Pain Overall Highest | Record of the highest pain level recorded. | This field should record the highest pain level recorded by the patient in the last 24 hours using the visual analogue scale. | |
LANSS | |||
S_LANSS | |||
Nurse Dependency Total | |||
Nurse Dependency Score | |||
AUKUH Acuity Tool | |||
Therapy Complexity Total | |||
Therapy Complexity Score | |||
RCScore Total | |||
RCScore | |||
Staff Indic_Value | |||
BRS Day | |||
ARS Day | |||
BCVS Day | |||
ACVS Day | |||
RS Day | |||
GIS Day | |||
LS Day | |||
DS Day | |||
NS Day | |||
BW day | |||
Organ Support Sum | |||
HDU day | |||
ICU day | |||
CritCare_Indic_Value | |||
Optv_event | |||
Operative_Indic_Value | |||
Consum_Indic_Value | |||
OP_event | |||
OPD_Indic_Value | |||
dep_Forename | |||
dep_Surname | |||
dep_HospitalID | |||
dep_Postcode | |||
dep_Postcode2 | |||
dep_DateOfInjury |