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Mass Trauma Data Instrument
The preferred
format to use for actual data collection is the PDF.
(Requires
Acrobat
Reader)
Abstractor_______________
Case#_______
Demographics
Facility:
__________________________ |
Date:
____/_____/_____ |
Time:
___________ (24 hr) |
Last Name:
___________________________ |
DOB:
____/_____/_____ |
Age:
______ yrs months |
First Name:
___________________________ |
Sex: M
F No Data |
|
Medical Record #:
______________________ |
Other:
____________________________________ |
Circumstances of Injury Reason
for Visit::
____________________________________________________________
How Did
the Injury Happen? ____________________________________________
____________________________________________________________________________
What Was S/he Doing?
_________________________________________________
____________________________________________________________________________
Where Did the
Injury Occur? _____________________________________________
____________________________________________________________________ Was
the Injury Caused by the Event?
Direct
Effect Indirect
Effect Not
Event Caused Uncertain
No
Data
How
Arrived: Ambulance
Public
Transportation Private
Vehicle
Walked/Carried
Other:
______________________ No
Data
Summary Information
Injury
Condition(s)
(Check all that apply):
Other
Condition(s) (Check all that apply):
Details of Conditions
- Condition
#1:_____________________________________________________
Body Part(s):______________________________
- Condition
#2:_____________________________________________________
Body Part(s):______________________________
- Condition
#3:_____________________________________________________
Body Part(s):______________________________
- Condition#4:_____________________________________________________
Body Part(s):______________________________
Content last
revised 3/10/03.
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