Current through Register Vol. 57, No. 6, March 17,
2025
(a) Every
hospitalization involving trauma resulting in spinal cord injury, as defined in
N.J.A.C.
8:94-1.3, occurring in New Jersey shall be
reported by each hospital ("reporting hospital") responsible for such
hospitalization.
(b) Each reporting
hospital shall designate an administrative contact person who shall have
primary responsibility for complying with the provisions of this subchapter on
behalf of the hospital. The reporting hospital shall submit the name, and
contact information of such person to the Registry Manager.
(c) A health care facility other than a
hospital or a health care provider may submit registry data on cases of spinal
cord injury, regardless of etiology, provided the content and form of such data
is compatible with the Registry.
(d) For each case of trauma resulting in
spinal cord injury, the reporting hospital shall report such data as is
required by the Registry Manager. The data required for each report shall
include, at a minimum, the following:
1.
Patient identifiers and demographics:
i. The
patient's name, address and phone number;
ii. The patient's social security
number;
iii. The patient's race,
gender, age and date of birth;
iv.
Ethnicity;
v. The medical record
number and/or billing control number; and
vi. The payment source;
2. BLS/ALS dispatch data:
i. The date and time of injury;
ii. The patient's location at time of
injury;
iii. The cause of
injury;
iv. The injury
type;
v. The date and time of
arrival of the first responder at the scene;
vi. Interventions at the scene and enroute to
hospital;
vii. The date and time
the patient departed scene; and
viii. The date and time the patient arrived
at hospital;
3.
Emergency room data:
i. The name of the
admitting hospital;
ii. The date
and time the patient arrived at the emergency room;
iii. Interventions at the emergency
room;
iv. The date and time the
patient was discharged from the emergency room;
v. The diagnosis at the time of discharge
from the emergency room;
vi. The
date and time the patient was admitted to the hospital;
vii. The date and time the patient was
discharged from the hospital;
viii.
The name and address of the facility the patient transferred to (if
applicable);
ix. The reason for the
transfer decision (if applicable); and
x. The responsible party for the transfer
decision (if applicable);
4. Injury description and diagnoses:
i. The type of personal protective
equipment;
ii. The motor vehicle
position (if applicable);
iii. The
injury context (work or sports related);
iv. The external cause of injury
narrative;
v. The external cause of
injury code (Ecode);
vi. Assault
and/or homicide circumstances (if applicable);
vii. ICD-10-CM Volume I diagnosis
code(s);
viii. Industry-standard
spine-abbreviated injury score, if available;
ix. Industry-standard head-abbreviated injury
score, if available; and
x.
Industry-standard injury severity score, if available.
5. Physiological and/or neurological status:
i. Substances identified upon initial
drug/alcohol screen;
ii. The level
of spinal cord injury;
iii. The
extent of spinal cord injury;
iv.
The diagnostic indication for intracranial lesion;
v. The diagnostic indication for skull
fracture;
vi. The level of
consciousness;
vii. Glasgow Coma
Scores (Eye, Motor, Verbal);
viii.
Glasgow patient status factors;
ix.
The ASIA Impairment Scale;
x. The
ASIA Motor Score (Left, Right, Total);
xi. The ASIA Light Touch Sensory Score (Left,
Right);
xii. The ASIA Pin Prick
Sensory Score (Left, Right);
xiii.
The total ASIA Sensory Score (Left Side);
xiv. The total ASIA Sensory Score (Right
Side);
xv. The presence of anal
contraction; and
xvi. The presence
of anal sensitivity;
6.
Treatment and outcomes:
i. ICD-10-CM Volume
III procedure code(s);
ii. The
administered medications;
iii. The
use of injectable steroid(s);
iv.
The time injectable steroid(s) administered;
v. The Glasgow Outcome Score;
vi. Functional independence measures/status
at discharge (self-feeding, locomotion and expression);
vii. The patient disposition at discharge;
and
viii. Autopsy findings, if any;
and
7. Was the patient
furnished a copy of the Registry enrollment form?
