IBID Field List

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This topic is for IBID


iBID Screens

Refer to the following iBID screens for detailed field information:

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