RED DE SANEAMIENTO

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44 4.12 EXAMPLE SUBMISSIONS

TARN submission example 1

Hospital: HOLBY “number” A (e.g. Holby1a) Opening Section

Gender Female

Full Date of Birth? Yes

Date of Birth 30/09/1975

Date Of Incident 01/12/2004

Date of Arrival at the Hospital 01/12/2004 Time of Arrival at the Hospital 12:01 Was the patient transferred? No

TARN Yes

Brief Injury Description

Upper and Lower Limbs Yes ---- - Open Fracture

---- - Vascular Injury ---- - Complex Hand Injury ---- - Neck or Femur Fracture

---- - Upper & Lower Limb Other Yes Pelvic Injuries

Penetrating Injuries Burns

Blunt Skin Injuries Yes ---Blunt skin injury Yes Other Injuries

Patient Details

Admission from

Emergency Dept Patient No Hospital Patient Number NHS Patient Number

Patient Surname/Family Name Jones

Patient Firstname Brenda

Patient Post Code (first part) M6 Patient Post Code (second part) 8HD

Nationality British

Incident

Description of incident

Time of Incident 11:30

Incident Post Code (first part) Incident Post Code (second part)

Type of Incident Location Public Area

Type of Injury Blunt

Mechanism of Injury Fall <2m Injury Intent Non intentional Incident information (additional) Pregnant

Trapped at Scene No

Enroute

Type of Transport Car

Emergency Department Date of Arrival 01/12/2004 Time of Arrival 12:01 Date of Leaving 01/12/2004 Time of Leaving 17:01 Trauma Team No Observations: Respiratory Date: 01/12/2004 Time: 12:10

Status of Airway: Normal

Breathing status: Normal

O2 Sat: 99%

Resp Rate: 20

Observations: Circulation

Date: 01/12/2004

Time: 12:20

Circulation Status: Unsupported

Pulse Rate: 70

BP: 120/60

Observations: Nervous System

Date: 01/12/2004

Time: 12:15

Sedation status: Unsedated

Power status: Normal

GCS: Missing assumed normal

Interventions Respiratory: Given oxygen

Host Defense: Simple reduction of # performed at

16.30 on 01/12/04

Attendants: Emergency Dept. Foundation yr 2 at 12.45 Orthopaedic 3rd _{SpR at 13.30}

Imaging Suite

Time of arrival 15:30 Investigations:

Date of xray: 01/12/2004

Time of xray: 15:40

Body region: Upper limb

Ward

Date of arrival 01/12/2004

Time of arrival 17:20

Type of ward Orthopaedic Ward

Injuries

Injury Descriptions Closed displaced fracture of left ulna.

Closed, comminuted fracture of right radius.

Bruising to left and right legs

Outcome

Pre-existing medical condition(s) None

Complication(s) None

Outcome at 30 days Alive Outcome at Discharge Alive Date of Discharge 06/12/2004 Time of Discharge Not known Days in critical care 0

Days Intubated 0

Discharged to Home

Glasgow Outcome Scale Moderate disability Generic Time of GOS On discharge

Re-Admission No

TARN submission example 2

Hospital: HOLBY “number” A (e.g. Holby1a) Opening Section

Gender Male

Full Date of Birth? Yes

Date of Birth 01/05/1967

Date Of Incident 31/01/2005

Date of Arrival at the Hospital 01/02/2005 Time of Arrival at the Hospital 00:25 Was the patient transferred? Yes out Is this hospital the 1st receiving hospital? Yes Next hospital St Elsewhere

TARN Yes

Brief Injury Description

Head Injuries ---- - Unconscious

---- - Intracranial Yes ---- - Depressed Skull Fracture

---- - Other Skull Fracture ---- - Other Head Injury Spinal Injuries

---- - Unstable Spine

---- - Cord Injury Yes

---- - Brachial Plexus Injury ---- - Spine Other

Patient Details

Patient Surname/Family Name Garcone

Patient Firstname Samuel

Patient Post Code (first part) Not known Patient Post Code (second part)

Nationality European

Incident

Scene details available Yes

Time of Incident 23:10

Incident Post Code (first part) Incident Post Code (second part)

Incident Location Dockyards Type of Incident Location Industrial

Type of Injury Blunt

Mechanism of Injury Fall >2m Injury Intent Non intentional Incident information (additional) Explosion

Trapped at Scene No At Scene Date called 31/01/2005 Time called 23:15 Date of Dispatch 31/01/2005 Time of Dispatch 23:18 Observations Respiratory: At 23:25 on 31/01/2005

Airway Status: Obstructed

Breathing Status: Respiratory distress Observations Nervous system: At 23.30 on 31/01/2005

GCS = 3 and both eyes pupil reactivity were noted as sluggish.

No other observations at scene

Interventions Respiratory: Manual ventilation

No other interventions

Attendants: He was seen by passing GP at 23:25

Enroute

Type of transport Helicopter Date of departure from scene 01/02/2005 Time of departure 00:15

Observations Respiratory: At 00:20 on 01/02/2005

Airway Status: Supported

Breathing Status: Manually ventilated

Attendants: Accompanied by GP to hospital

Emergency Department

Date of Arrival 01/02/2005

Time of Arrival 00:25

Date of Leaving 01/02/2005

Time of Leaving 01:35

Trauma Team Yes

Observations: Respiratory

Date: 01/02/2005

Time: 00:25

Status of Airway: Supported

Breathing status: Manually ventilated

O2 Sat: 90%

Date: 01/02/2005

Time: 00:25

Pulse Rate: 60

BP: 140/60

Observations: Nervous System

Date: 01/02/2005

Time: 00:25

Power status: General weakness

GCS: Total = 3

Pupils: Both sluggish

Sensation Deficit recording: Reduced No other observations taken

Interventions Respiratory: Intubated and ventilated at 00:30 Interventions Metabolism: Bladder catheter inserted at 00:45

Attendants: The trauma team was called and he was met on

arrival at 00:25 by:

ATLS trained Emergency department Consultant, Emergency department SHO.

Neurosurgical 5th _SpR,

Consultant Anaesthetist and SpR spinal.

He was seen by Consultant neurosurgeon at 00.40.

Imaging Suite

Date of Arrival 01/02/2005

Time of Arrival 01:40

Investigations Imaging: CT scan of Head and spine was performed by 4th

year SpR radiologist at 1.45.

The CT scan report was emailed to Neurosurgical unit at 2nd _hospital

Specify if image normal No

Specify abnormality Contusion to C spine

Injuries

Injury Descriptions Large Extradural haematoma on the left side. Incomplete cord syndrome contusion to the spinal cord at C2 level with no fracture.

Hospital Transfer

Transfer To Another Hospital

Request Date of Transfer Out 01/02/2005 Request Time of Transfer Out 02:30

Reason Neurosurgery

Date of departure 01/02/2005

Time of departure 03:05

Date Of Arrival 01/02/2005

Time of Arrival 04:30

Attendants: SpR Neurosugeon and an spinal nurse

accompanied the patient to 2nd _hospital.

Outcome

Pre-existing medical condition(s) Epilepsy and Osteoarthritis Complication(s) Not known

Comments

Outcome at 30 days Not known Outcome at Discharge Alive Date of Discharge 01/02/2005

Time of Discharge 03:05

Length of Stay (days)

Days in critical care 0

Days Intubated 1

Discharged to Other acute hospital Glasgow Outcome Scale Severe disability Generic Time of GOS At discharge

Re-Admission

Re-admission No

TARN submission example 3

Summary

Hospital: Your individual HOLBY “number” A (e.g. Holby1a)

Opening Section

Gender Male

Full Date of Birth? No

Date of Birth

Short Date of Birth (mm/yyyy)? No Short Date of Birth

Age 15

Date Of Incident 05/01/2005

Date of Arrival at the Hospital 05/01/2005 Time of Arrival at the Hospital 15:10

Was the patient transferred? Transferred out Is this hospital the 1st receiving hospital? Yes

Next hospital St Elsewhere

TARN Yes

Brief Injury Description

Head Injuries Facial Injuries Neck Injuries Thoracic Injuries

Abdominal Injuries Yes

---- - Organ Injury Yes ---- - Vessel Injury

---- - Urological Injury ---- - Other Abdominal Injury Spinal Injuries

Upper and Lower Limbs Yes

---- - Open Fracture

---- - Vascular Injury ---- - Complex Hand Injury ---- - Neck or Femur Fracture

---- - Upper & Lower Limb Other Yes Pelvic Injuries

Penetrating Injuries Burns

Blunt Skin Injuries Yes ---- - Blunt Skin Injury Yes

---- - Degloving Other Injuries

52

Patient Details

Patient Surname/Family Name Jones

Patient Firstname David

Patient Post Code (first part) WA12 Patient Post Code (second part)

Nationality British

Incident

Scene details Joyriding in stolen car and traveling 100+ mph when hit back of braking car in front.

Time of Incident 14:30

Incident Post Code (first part) Incident Post Code (second part)

Incident Location Junction 2 on M62 Type of Incident Location Road

Type of Injury Blunt

Mechanism of Injury Vehicle collision Injury Intent Suspected High Risk Incident information (additional) Evidence of alcohol

Position in VI Driver Protection in VI Airbag Trapped at Scene No At Scene Ambulance Details Date called 05/01/2005 Time called 14:35 Date of Dispatch 05/01/2005 Time of Dispatch 14:37

Interventions Respiratory: Oxygen started at scene

Attendants: Paramedic and Technician from Mersey Ambulance attended to patient both at 14:45 on 05/01/2005

En Route

Type of Transport Ambulance

Date of Departure from Scene 05/01/2005 Time of Departure from Scene 15:00

Emergency Department Date of Arrival 05/01/2005 Time of Arrival 15:10 Date of Leaving 05/01/2005 Time of Leaving 17:00 Trauma Team No Observations: Respiratory Date: 05/01/2005 Time: 15:15

Status of Airway: Normal

Breathing status: Added oxygen

O2 Sat: 97%

Resp Rate: 25

Observations: Circulation

Date: 05/01/2005

Time: 15:25

Circulation Status: Unsupported

Pulse Rate: 80

BP: 100/50

Observations: Nervous System

Date: 05/01/2005

Time: 15:20

Sedation status: Not sedated

Power status: Normal

GCS: Total = 15

No other observations taken

Investigations: Ultrasound to abdomen performed whilst under care of E.D at 16:05

X-ray to chest performed in E.D. at 15:50 Interventions Metabolism: Bladder catheter inserted at 15:40 Attendants: Seen by Emergency Dept SHO at 15:30

Emergency Dept. Nurse at 15:15

Consultant General Surgeon at 16:30

Ward

Date of arrival 05/01/2005

Time of arrival 17:15

54

Injuries

Injury Descriptions 2cm long laceration to liver with blood loss of 200mls.

Lung contusion to left side.

Simple, Closed # to 5th _{metacarpal on right hand.}

Abrasion to right hand

Hospital Transfer

Transfer To Another Hospital

Request Date of Transfer Out 06/01/2005 Request Time of Transfer Out 14:30

Reason Further specialist care

Date of departure 06/01/2005 Time of departure 21:45 Transport Ambulance Date Of Arrival 06/01/2005 Time of Arrival 23:10 Outcome

Pre-existing medical condition(s) Asthma and Drug Abuse

Complication(s) None

Comments

Outcome at 30 days Alive Outcome at Discharge Alive Date of Discharge 06/01/2005

Time of Discharge 21:45

Days in critical care 0

Days Intubated 0

Discharged to Other Acute Hospital Glasgow Outcome Scale Not Available

Generic Time of GOS

Re-Admission

Re-admission Yes

Route From other hospital

Date 08/01/2005

Time 12:00

Discharge Status Alive

Date of discharge 10/01/2005

Time of discharge Not known

Discharged to Mothers home

In document INGENIERÍA SANITARIA (página 120-140)