S-4.2, r. 27 - Regulation respecting the transmission of information on users who are major trauma patients

Section 1 Disposition versions

2012-09-01

1. Institutions operating a hospital of the general and specialized class of hospitals and designated by the Minister under section 112 of the Act respecting health services and social services (chapter S-4.2) to operate a trauma centre shall provide the Minister with the following information on users who are major trauma patients:

(1)  trauma registry number;

(2)  user’s medical file number;

(3)  receiving institution’s code number;

(4)  transferring institution’s code number;

(5)  user’s health insurance number;

(6)  user’s date of birth;

(7)  user’s sex;

(8)  user’s home postal code;

(9)  municipal code of the accident site;

(10)  paying agency;

(11)  user’s occupation;

(12)  date and time of the accident;

(13)  location of the accident;

(14)  transport service or mode of transport to the institution’s facility;

(15)  date and time of arrival in the emergency room;

(16)  date and time of admission and admitting physician’s specialty;

(17)  date and time of admission to each unit;

(18)  site of the medical and surgical interventions;

(19)  cause of the trauma;

(20)  individual’s position in the vehicle;

(21)  safety equipment worn by the user;

(22)  alcohol and drug test results;

(23)  status upon arrival in the emergency room;

(24)  date, time and results of peritoneal lavage;

(25)  intubation in the emergency room;

(26)  use of pneumatic anti-shock garments in the emergency room;

(27)  chest tube in the emergency room;

(28)  specialties consulted;

(29)  dates and times of requests for consultations and responses;

(30)  pre-hospital interventions (oxygen, splints, pneumatic anti-shock garments, dressings, intravenous lines, immobilizations, mechanical ventilation, medication, release, resuscitation);

(31)  resuscitation attempts;

(32)  date, time and number of intravenous injections;

(33)  date, time and number of blood transfusions;

(34)  date, time and code of medical and surgical interventions;

(35)  date and time of departure from the emergency room;

(36)  status and referral at departure from the emergency room;

(37)  date and time of the start and end of mechanical ventilation;

(38)  date and nature of paramedical assessment;

(39)  date of the start and nature of paramedical treatment;

(40)  date and time of the onset and nature of complications;

(41)  report to the coroner;

(42)  autopsy performed;

(43)  cause of death on the certificate;

(44)  organ donation or transfer for organ donation;

(45)  body region injured;

(46)  type of injury;

(47)  injury code in accordance with the Abbreviated Injury Scale (AIS);

(48)  injury severity in accordance with the Injury Severity Score (ISS);

(49)  level of consciousness;

(50)  vital signs (rate and type of respiration, pulse rate, blood pressure, eye opening, verbal response, motor response, pupil size and reactivity, intracranial temperature and pressure);

(51)  physiological scales (Pre-Hospital Index (PHI), Glasgow Coma Scale (GCS) and Revised Trauma Score (RTS));

(52)  body regions examined by radiology;

(53)  date, time and results of radiology examinations;

(54)  degree of memory function / amnesia;

(55)  Glasgow Outcome Score (GOS);

(56)  body regions examined by CAT scanning;

(57)  dates and times of requests for and receipt of CAT scans;

(58)  results of CAT scanning;

(59)  signs of injury to central nervous system on CAT scan;

(60)  Levin scale;

(61)  degree of functional independence;

(62)  neurological history;

(63)  history of cranial trauma;

(64)  type and date of paralysis prior to accident;

(65)  status and referral at departure from admission;

(66)  date of discharge from hospital;

(67)  code of institution to which user is transferred;

(68)  diagnostic codes (in accordance with the International Classification of Diseases adopted by the World Health Organization (ICD)).

O.C. 981-2000, s. 1.