Introduction

The emergency department (ED) record is the source document for all NEISS reporting. The NEISS Coordinator uses the information in the ED record to determine if a case is “in scope” (eligible for reporting) and to extract the required surveillance data for NEISS coding and reporting. It is important that all ED records be complete, accurate, and available for review in a timely manner.

As a NEISS Coordinator, you should be very familiar with your hospital’s ED record flow system. Each hospital’s system is unique, but here are some common elements:

• ED Logs ­ a daily listing of each emergency department visit (ERV).
• Record Flow ­ when records are completed and available for review.
• Record Sources ­ where records are generated and how they are maintained.
• Record Transmittal ­ how records are transmitted to those who use them.

Get to know the people involved in the ED record flow system at your hospital. It is only with their help that you will be able to get complete, accurate, and timely data for your NEISS report.

Lesson Topics

Introduction - Record Flow

The primary mission of an emergency department is treating the sick and injured. Keeping ED records is important, but secondary. However, for a NEISS Coordinator, the ED records are of primary importance. Become familiar with your hospital’s ED record schedule by asking these questions:

• When will a complete record be available for my review? 
• What are the bottlenecks and obstacles to a timely review of records?
• How and when can I expedite record transmittal?

Learning the answers to these questions will help you achieve the NEISS goal of accurate and timely reporting.

Lesson Topics

Introduction - ED Logs

ED logs are generated at each entry point of a hospital’s emergency department. The logs capture basic information about each ED visit such as date, time, nature of complaint, and any other information the hospital may deem relevant. Use the ED log to assure that all relevant ED records are evaluated for NEISS eligibility.

Lesson Topics

Reconciling Records

Remember, the injury and illness data you report through NEISS is a statistical representation of injuries and illnesses in approximately 5000 U.S. hospitals. Even small errors and omissions, if repeated and widespread, can have a significant effect on the accuracy of the estimates.

Reconciling the ED records with the ED log is an important step in assuring comprehensive and accurate reporting because it confirms that you have an ED record for each emergency department visit (ERV) recorded in the log. If the records and log are not in agreement, you must resolve the difference to confirm that all available ED records are collected for review.

Lesson Topics

Collecting Records

The success of NEISS depends upon reporting accurate and timely data. Care must be taken to identify, correctly code, and enter into the computer all appropriate cases. A complete case record has all the information you need to accurately make a NEISS report. Most important is information about the patient, the incident, the injury, and the product(s) associated with the injury.

Each time you work with NEISS you should:

• Collect and review the records for all emergency cases seen in your emergency department to determine whether an in-scope injury or illness is mentioned.
• Make sure all cases that are part of the hospital’s emergency system are collected and reviewed for every treatment date and for every point of entry into the system.
• Include all fatalities for which an emergency department record was completed. 
• Include all emergency department cases where the patient was later admitted for hospitalization in the same facility or transferred to a different facility.
• Exclude ED records for patients transferred from another facility.

Lesson Topics