The study of trauma has been handicapped from its inception by the absence of a single coherent method of cataloging injuries. The AIS and ICD-9 systems have failed to fill this void because they lack the precision necessary to describe surgically treated injuries. We conceived a simple system of injury description in which injuries are rapidly encoded using a microcomputer in sufficient detail to distinguish among millions of different injuries. This system is easily searched by a microcomputer and allows for the automatic assignment of AIS, ISS, and CPT codes. In this system a patient is described by a ‘paragraph’ consisting of any number of identically patterned ‘sentences,’ each describing one of the patient’s injuries. Each ‘sentence’ is composed of a string of six ‘words’ from controlled vocabularies and has the following structure: “Body region, Organ, Anatomic region, Injury, Physiology, Treatment.” Defining the vocabulary allowed for each ‘word’ in a ‘sentence’ is complex because the allowed vocabulary is dependent upon the preceding ‘words’ in a ‘sentence,’ but in practice a microcomputer simply provides short lists of acceptable choices at each step of injury description, and records the user’s selections. Additionally, the microcomputer assigns AIS, ISS, and CPT codes appropriate to the injury description sentence. The ease of data entry, the fineness of detail captured, the automation of code assignment, and the accuracy of database searching for specific injuries, classes of injuries, or combinations of injuries, we believe will give this approach widespread application in academic trauma centers where an accurate and accessible trauma database is important. © 1990, by The Williams & Wilkins Co.
