1. An institution referred to in section 5.1 of the Regulation must provide the following information:
(1) concerning the user and the traumatic event:
(a) the name and number, on the institution’s permit, of the facility that provides the data;
(b) the sequence number assigned to the traumatic event;
(c) the code of the municipality where the user’s residence is located;
(d) the geographic code of the user’s residence;
(e) the reason for which the health insurance number cannot be provided, where applicable;
(f) the date and time of the trauma;
(g) the code of the municipality where the trauma occurred;
(h) the geographic code of the place where the trauma occurred;
(i) the cause of the trauma;
(j) the place where the trauma occurred;
(k) an indication that the trauma occurred when the user was at work;
(l) the external cause responsible for the trauma according to ICD-10-CA;
(m) the activity carried on by the user when the trauma occurred, according to ICD-10-CA;
(n) the type of medical insurance under which the user is compensated;
(o) the user’s role at the time of the trauma;
(p) the safety equipment used or worn by the user at the time of the trauma, where applicable;
(2) concerning the delivery of pre-hospital emergency services to the user or collected during delivery:
(a) the date and time of reception, at the health communication centre, of the call from a 9-1-1 emergency centre requesting the intervention of pre-hospital emergency services;
(b) the method of transportation to the first facility of the institution where the user was received;
(c) the date and time of arrival of the first responder at the user’s side, where applicable;
(d) the date and time of arrival of the ambulance at the scene of the trauma;
(e) the date and time of departure of the ambulance from the scene of the trauma;
(f) the distance travelled by the ambulance, in kilometers, between the scene of the trauma and the first installation where the user was received;
(g) the number of the form to declare transportation by ambulance;
(h) the number of the pre-hospital intervention report;
(i) an indication that the user had to be extricated from a vehicle that had been in an accident;
(j) an indication that the Échelle québécoise de triage préhospitalier en traumatologie was used;
(k) the criterion used to direct the user to the first facility under the Échelle québécoise de triage préhospitalier en traumatologie;
(l) the score on the GCS (Glasgow Coma Scale);
(m) an indication that there was immobilization of the user’s rachis or spine;
(n) the user’s respiratory rate;
(o) the user’s pulse;
(p) the user’s systolic blood pressure;
(q) the date and time of any cardiorespiratory arrest;
(r) an indication that oxygen was used;
(s) the user’s percentage of oxygen saturation;
(t) an indication that respiratory support, ventilatory support, a combitube or a neck brace was used;
(u) the name and number, on the institution’s permit, of the first facility where the user was received;
(v) the date and time of arrival at that facility;
(w) the number of the user’s record at the first facility where the user was received;
(3) concerning the user’s visits to any emergency department and any consultation requested therein:
(a) the method of transportation to the emergency department;
(b) the user’s origin upon arrival in the emergency department;
(c) the name and number, on the institution’s permit, of the facility of origin upon arrival in the emergency department, where applicable;
(d) the name and number, on the institution’s permit, of the facility where emergency care was provided to the user;
(e) the date and time of the user’s arrival in the emergency department;
(f) an indication that the user was alive or dead upon arrival in the emergency department;
(g) the sequence number assigned to the consultation;
(h) the field of consultation;
(i) the date and time of the request for consultation;
(j) the date and time of the consultation;
(k) the date and time of the user’s departure from the emergency department;
(l) the user’s destination upon departure from the emergency department;
(m) the name and number, on the institution’s permit, of the facility that is the user’s destination upon departure from the emergency department, where applicable;
(4) concerning the user’s admission to and departure from the institution that provides the data:
(a) the method of transportation to the institution where the user was admitted;
(b) the user’s origin upon admission;
(c) the name and number, on the institution’s permit, of the user’s facility of origin upon admission, where applicable;
(d) the date and time of the user’s admission;
(e) an indication that the user was transferred to an institution in the user’s region of origin for continuity of care;
(f) the sequence number assigned to any service the user was registered for;
(g) the code and description of any service the user was registered for;
(h) the date and time of registration of the user for any service;
(i) an indication that the user was brought directly to the surgical suite upon admission;
(j) the sequence number assigned to any physical care unit in which the user stayed;
(k) a description of the physical care unit in which the user stayed;
(l) the date and time of the user’s arrival at any physical care unit in which the user stayed;
(m) the date and time of the user’s departure from any physical care unit in which the user stayed;
(n) the date of any application for the user’s transfer to another institution operating a hospital of the general and specialized class of hospitals;
(o) the date and time of the user’s departure from the institution;
(p) the user’s destination upon departure from the institution;
(q) the name and number, on the institution’s permit, of the facility that is the user’s destination upon departure from the institution, where applicable;
(5) concerning any taking of the user’s vital signs in any emergency department or during the user’s stay in the institution;
(a) the date and time the user’s vital signs were taken;
(b) the degree of eye opening;
(c) the user’s verbal response;
(d) the user’s motor response;
(e) the score on the GCS (Glasgow Coma Scale);
(f) an indication that the user’s level of consciousness was artificially modified;
(g) the type of modification of the user’s level of consciousness;
(h) the user’s type of respiration;
(i) the user’s number of respiratory cycles per minute;
(j) the user’s pulse;
(k) the user’s systolic blood pressure;
(l) the user’s diastolic blood pressure;
(m) an indication that oxygen was administered to the user;
(n) the user’s percentage of oxygen saturation;
(o) the user’s body temperature;
(p) the score on the RTS (Revised Trauma Score) physiological scale;
(q) the user’s intracranial pressure;
(6) concerning any examination requested for the user or any intervention carried out for the user in any emergency department or during the user’s stay in the institution:
(a) an indication that a radiographic assessment of the user was conducted;
(b) an indication that alcohol intoxication was suspected;
(c) the result of an alcohol intoxication test;
(d) the result of a drug intoxication test;
(e) the date and time a chest drain was inserted;
(f) the date and time of a FAST (Focused Assessment with Sonography in Traumatology);
(g) the date and time an intravenous line was inserted;
(h) the date and time of an intubation;
(i) the date and time of a gasometry;
(j) the date and time of a lactate measurement;
(k) the sequence number assigned to a medical imaging test;
(l) the type of medical imaging test requested for the user;
(m) the part of the user’s body for which a medical imaging test was requested;
(n) the date and time of the request for a medical imaging test;
(o) the date and time a medical imaging test was conducted;
(p) the sequence number assigned to an intervention;
(q) the code and description of an intervention according to the CCI;
(r) the codes of the status, location and extent attributes of an intervention according to the CCI;
(s) the number of interventions carried out for the user;
(t) the date and time of an intervention;
(u) the place where an intervention was carried out;
(v) the date and time of the user’s departure from the operating room, where applicable;
(w) the sequence number assigned to mechanical ventilation treatment;
(x) the date and time of the start of mechanical ventilation treatment;
(y) the date and time of the end of mechanical ventilation treatment;
(z) the paramedical consultations conducted for the user;
(aa) the date and time of the first paramedical consultation;
(7) concerning any diagnosis established for the user, as well as the user’s death, where applicable:
(a) the sequence number assigned to the AIS (Abbreviated Injury Scale) code;
(b) the AIS code identifying each injury that was diagnosed;
(c) the diagnoses established according to ICD-10-CA;
(d) an indication that there was penetrating trauma and the part of the body affected;
(e) the result of the computation of the ISS (Injury Severity Score);
(f) the result of the computation of the PS_ISS (Probability of Survival Injury Severity Score);
(g) the result of the computation of the NISS (New Injury Severity Score);
(h) the presence of craniocerebral trauma (CCT) and the severity of that trauma;
(i) the presence, in the user, of a medullary injury and the type of medullary injury;
(j) the sequence number assigned to the complications presented by the user;
(k) the code and description of a complication according to ICD-10-CA;
(l) the sequence number assigned when comorbidity was registered for the user;
(m) the nature of the comorbidity;
(n) an indication that an autopsy of the user was conducted;
(o) an indication that it is a coroner’s case where there is reason to notify the coroner under the Act respecting the determination of the causes and circumstances of death (chapter R-0.2);
(p) an indication that organs were removed for donation;
(8) concerning users who are serious burn victims:
(a) the circumstances surrounding the user’s burn or burns;
(b) the type of burns and a description of the burns;
(c) the user’s colour or ethnic origin;
(d) the user’s occupation;
(e) the user’s weight upon arrival at the facility and upon departure from that facility;
(f) an indication that the user has inhaled fumes that may be made of corrosive or toxic gases;
(g) the user’s carboxyhaemoglobin level;
(h) an indication that the use of a cell culture was necessary;
(i) an indication that the user had already suffered burns prior to the traumatic event;
(j) an indication that the user underwent a skin graft during the user’s stay at the facility;
(k) an indication that the user was infected with MRSA (methicillin-resistant Staphylococcus aureus);
(l) an indication that the user was infected with VRE (vancomycin-resistant Enterococci);
(m) an indication that an agent was used to increase pressure in the user’s blood vessels (vasopressor);
(n) specific interventions carried out for the user.