Table 5. Examples of Clinical Data Elements for a Minimum Data Set for Orthopedic Injuries.

Data Class
Diagnostic data
Chief complaint
Primary diagnosis
Final diagnosis
Other diagnosis
Body part injured
Fracture direction
Emergency data
Injury Date
Injury time
Transported by land ambulance
Transported by air ambulance
Dispatch date
Dispatch time
Anesthesia data
Kind of anesthesia
Anesthesia drug
Start of anesthesia
End of anesthesia
anesthesia time
Anesthesia risk level
Procedure data
Date of procedure
Procedure name by ICD-9-CM
Date of surgery
Start of operation
End of operation
Internal fixation
External fixation
History
Past disease history
Drug or food allergy
Family history
Fracture history
Consultations
Consultation with service requests
Type of consultation
Consultation date
Consultation time
Orders
Inpatient order
Blood reserve order
Radiography orders
Dietary orders
Order date
Order time
Follow up
Request Rehabilitation
Type of Rehabilitation
Number of meetings
activity
Death data
The main cause of death
Underlying cause of death
External causes of death
Date of death
Place of Death
X-rays
Type of requested radiography
Limb’s name
Limb’s direction
Date of radiography
Radiologist diagnosis
Lab-tests
Requested test
Pathology reports
Tests Results
Pathology results
Date
Medications
Name and type of medications
Value
Dose
Type of Prescription
Instrument
Name of the requested
instrumentsSize
Serial number
date of produced
Manufacturer
Blood products
Blood request
Blood type
Unit
Blood pack serial number
Nursing note
Nursing report
Date of report
Time of report
Confirm orders by nurses
Patient education
Conditions of discharges
Discharge date
Discharge time
Medication instructions at
discharge
Places to visit follow up
Transfer data
Cause of dispatch or transfer
Transfer date
Origin hospital
Transfer time
Destination hospital