Hospitals, as defined in G.S. 130A-480(d), shall submit electronically to the Division of Public Health the following electronically available emergency department data elements for all emergency department visits:

1. (1) Patient record number or other unique identification number;
2. (2) Patient date of birth and age;
3. (3) Patient's sex;
4. (4) City of residence;
5. (5) County of residence;
6. (6) Five digit ZIP code;
7. (7) Alpha numeric patient control number assigned by the hospital for each record (the Visit Identification Number);
8. (8) Emergency department facility identification number;
9. (9) Projected payor source;
10. (10) Date and time of emergency department visit (first documented time);
11. (11) Mode of transport to the emergency department;
12. (12) PreMIS identification number, if transported by EMS;
13. (13) Chief complaint;
14. (14) Initial temperature reading and route;
15. (15) Initial systolic and initial diastolic blood pressure;
16. (16) Triage Notes (brief description of patient's/family's self-reported illness episode, including symptoms, duration of symptoms, and reasons for visit [in addition to Chief Complaint] as presented by the patient or family to the triage nurse upon arrival at the emergency department) – this element is optional;
17. (17) Initial emergency department acuity assessment;
18. (18) Coded cause of injury (ICD-9-CM, if injury related to diagnosis);
19. (19) Emergency department procedures, up to ten (CPT or ICD-9-CM or ICD-10-CM);
20. (20) Emergency department disposition;
21. (21) Emergency department disposition diagnosis description; and
22. (22) Emergency department disposition diagnosis codes, one primary and up to ten additional (ICD-9-CM or ICD-10-CM).

History Note: Authority G.S. 130A-480;
Eff. January 1, 2005;
Pursuant to G.S. 150B-21.3A, rule is necessary without substantive public interest Eff. January 9, 2018.