N.J. Admin. Code § 8:94-4.2

Current through Register Vol. 56, No. 9, May 6, 2024

Section 8:94-4.2 - Reporting requirements

(a) Every hospitalization involving trauma resulting in spinal cord injury, as defined in 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?

N.J. Admin. Code § 8:94-4.2

Amended by 47 N.J.R. 527(c), effective 1/26/2015

Amended by 53 N.J.R. 2007(b), effective 12/6/2021