Ala. Admin. Code r. 420-7-4-.04

Current through Register Vol. 43, No. 02, November 27, 2024

Section 420-7-4-.04 - Data To Be Reported

(1) Head injury is defined as an occurrence of injury to the head that is documented in a medical record, with one or more of the following conditions attributed to head injury:

(a) observed or self-reported decreased level of consciousness;

(b) amnesia;

(c) skull fracture;

(d) objective neurological or neuropsychological abnormality;

(e) diagnosed intracranial lesion; and

(f) as an occurrence of death resulting from trauma, with head injury listed on the death certificate, autopsy report, or medical examiner's report in the sequence of conditions that resulted in death.

This definition applies to an acquired injury to the brain. This term does not include brain dysfunction caused by congenital or degenerative disorders, nor birth trauma, but may include brain injuries caused by anoxia due to near drowning. Spinal cord injury is defined as occurrence of an acute traumatic lesion of neural elements in the spinal canal (spinal cord and Cauda equina), resulting in temporary or permanent sensory deficit, motor deficit, or bowel or bladder dysfunction. All confirmed cases of head and/or spinal cord injury with the following International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM)* diagnostic codes as a primary and/or secondary diagnosis must be reported:

800.0-801.9 Fracture of the vault or base of the skull

803.0-804.9 Other and unqualified and multiple fractures of the skull

850.0-854.1 Intracranial injury, including concussion, contusion, laceration, and hemorrhage

806.0-806.9 Fracture of vertebral column with spinal cord lesion

*May also use International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) or any other newer version when appropriate.

952.0-952.9 Spinal cord lesion without evidence of spinal bone injury

(2) A report shall also be given for each subsequent head and/or spinal cord injury diagnosed in an individual. If it cannot be decided whether a case should be reported, the AHSCIR should be contacted for guidance.

(3) All electronically submitted reports of confirmed cases of head and/or spinal cord injury shall include but not be limited to the data items listed in the AHSCIR Data Acquisition Manual.

Author: Teresa S. Pells, M.P.H.

Ala. Admin. Code r. 420-7-4-.04

New Rule: Filed November 18, 1998; effective December 23, 1998.

Statutory Authority:Code of Al. 1975, § 22-11C-1, etseq.