IDENTIFICATION Last Name
First Name
REGISTER YEAR
MONTH
DAY
DAY
MONTH
BIRTHDAY minors of 12 years
AGE
RESIDEN CE
Y R
SEX M
F
Occupation Education
Year Completed
DEPT
MUNICIPALITY
ADDRESS
DEPT
MUNICIPALITY
ADDRESS
Place where the injury occurred
II- GENERAL DATA OF EVENT
(CLOSE IN CIRCLES ) (For every variable check only one )
Day and Hour : HISTORY Mon
Tue
DAY
Wed
Thur
MONTH
Fri
YEAR
Sat
Sun
INTENTIONALITY
HOUR
1-Non intentional (“accidents “ ) 2-Self-inflicted ( intentional :suicides o
DAY AND HOUR: EVENT
attempts )
3-Intentional (interpersonal violence, assaults )
Mon
Tue
DAY
Wed
Thur
MONTH
Fri
Sat
YEAR
PREVIOUS ATTENTION
Sun
N O
WHERE
HOSPITAL
MECHANISM OF INJURY (IES) (How was the injury sustained?)
HOUR
YE S
ATTENTION IN PUBLIC
8-Other____________________ 9-Unknown
YE S
N O
ACTIVITY What were you doing when you were injured? 1-Working 2-Studying 3-Sports 4-Travelling 5-Recreation/leisure 6-Drinking alcohol 8-Other_____________________ 9-UNKNOWN
PLACE Where were you when you were injured? 1-Home 2-School 3-Street 4-Work 5- Bar, or similar 8-Other_____________________ 9-UNKNOWN
1-Transport Injury 2-Sexual assault 3-Falls : a)same level b)other level ( ……..mts) 4-Blunt force 5-Stab/Cut 6-Gunshot
7-Fire/Smoke/heat
11-Explosiona) landmines
a )fire/smoke/flame b) warm liquids c)fireworks
b) other explosives …………
8-Choking/Strangulation 9-Drowing/ near drowning 10-Poisoning a)drugs……………………….……………… b)pesticides……………….......................... c)cooking fuel ( e.g kerosene……………… d) cleaning agents ………………………..
12- Bite a)Person b)Animal ______________ 13-Electricity 14- Natural Disaster____________ 15- Contact with Foreign Body 88-Other_____________________ 99-Unknown
III-INJURY MODULES INTERPERSONAL VIOLENCE or ASSAULTS
MOTOR VEHICLE RELATED MODE OF TRANSPORT (How was the injured person traveling?)
1. Pedestrian 2-Bicycle 3-Motorcycle 4-Car 5-Pick-Up 6-Truck 7a-Bus 7b-Microbús 8-Cart/animal 9-Taxi 88-Other_________ 99-Unknown
ROAD USER (what was the role of the injured person ) 1-Pedestrian 2-Driver 3-Passanger 8-Other________ 9.Unknown Safety elements
1-seat belt (Y) ( N) ( U/K) 2-helmet (Y) ( N) ( U/K) 3-Kids car seat (Y) ( N) ( (U/K)
IV- OTHER DATA ABOUT THE INJURIES
Previous episode
no
yes
Nº_____
SELF-INFLICTED Previous episode
no yes
Nº____
COUNTERPART What the Injured hits ?
1. Pedestrian 2-Bicycle 3-Motorcycle 4-Car 5-Pick- up 6-Truck 7a-Bus 7b-Microbús 8-Cart/Animal 9-Taxi 10-Fixed Object 88Other_________ 99-Unknown
RELATIONSHIP PERPETRATOR TO THE VICTIM 1-Partner or ex-partner 2a-Parents 2b-Step-parents 3-Other relatives 4-Friends /Known person 5-Unknown person 8-Other_____________ 9-Unknown
CONTEXT 1-Quarrel/Fight 2-Burglary or robbery 3-Sexual Assault 4-Gang activity 5-Family Violence/ Domestic violence 6-Lost bullet 8-Other____________ 9-Unknown
PRECIPITATING FACTORS 1-Conflict with family 2-Physical illness 3-Psycological condition 4-Financial problems 5-Legal system encounters 6-Death of family member 7-Victim of sexual or physical abuse 8-Conflict with partner/boyfriend 9- Difficulties with school 10- Unexpected pregnancy 88-Other _______________ 99-Unknown
VICTIM / INJURED PERSON (IF THE DRIVER IS THE VICTIM PUT HERE THE INFORMATION )
ALCOHOL USE
OTHER PSYCHOACTIVE SUBSTANCE SEX OF PERPETRATOR 1-Male 2-Female 9-Unknown
1- NO SUSPICION OR EVIDENCE
1- NO SUSPICION OR EVIDENCE
2- YES, THERE IS SUSPICION OR
2- YES, THERE IS SUSPICION, WHICH
EVIDENCE
__________________________________
9- UNKNOWN
9- UNKNOWN
V- CLINICAL DATA ANATOMIC PLACE OF THE INJURY( IES ) (You can check more than one )
SEVERITY 1-Minor or superficial (e.g. bruises, minor cuts)
NATURE OF THE INJURY 1-Head 2-Face 2-Neck 3-Eyes 4-Ears 5-Nose 6-Thorax 7-Back 8-Abdomen
9- Pelvis /genitals 10-Shoulder/Arm 11-Elbow/Forearm 12-Wrist/Hand/Fingers 13-Hip/Thigh 14-Knee/legs 15-Ankle/Feet/Toes 16-Multiples 88-Other__________
1-Laceration, abrasion, 2-Cut/Wound/Bite 3- Systemic Organ Injury 4-Strain/Sprain or Dislocation 5-Fracture 6-Burn 7-Bruise , contusion 8-Trauma Brain 88-Others________________ 99- Unknown
2-Moderate, requiring some skilled treatment ( e.g. fractures, sutures )
3–Severe, requiring intensive medical/surgical management (e.g. internal hemorrhage, punctured organs, severed blood vessels) ICD X-DIAGNOSIS
Physician
REASON FOR CONSULTATION :
EXISTING DISEASES OR HEALTH PROBLEM
DISCHARGE CONDITION 1) alive 2) died
DISPOSITION 1-Treated and discharged 2-Admitted in the hospital 3-Refered to other hospital:___________________ 4-Escape 5-Voluntary abandonment 6. Unknown
LAST TIME OF MEAL
HOUR OF ATTENDANCE
BACKGROUND
PHYSICAL EXAM HR:
RR:
Tº:
BP:
INJURIES SCHEME
fdfdfdfdfd
WEIGHT
______Kg HEIGHT
cm
GLASGOW:
Points
INITIAL DIAGNOSIS
INITIAL TREATMENT
COMPLETED by (Signature and stamp) PROCEDURES IMPLEMENTED
SUPERVISOR (Signature and stamp)
AUTORIZATION (Signature and stamp )
