Trauma: Wisconsin Admin. Code ch. DHS 118 and Site Review Resources
Wisconsin Stat. § 256.25(2) promulgates the Wisconsin Department of Health Services (DHS) with the development of standards used to classify level III and IV hospital emergency capabilities. Wisconsin Admin. Code ch. DHS 118 went through an administrative rule rewrite and updated the standards based on the most recent standards developed by the American College of Surgeons. The new standards went into effect on Oct. 1, 2021.
Site review resources
Site review documents are intended for trauma program staff utilization to prepare for their schedule trauma care facility site review. If you are unsure of when your next trauma care facility site review is, email DHSTrauma at DHSTrauma@dhs.wisconsin.gov.
General
- TCF Classification Site Review Agenda (PDF)
- Trauma Care Facilities (TCF) Classification Process (PDF)
- Trauma Care Facilities Standards Comparison, P-02967 (PDF)
- Level III Criteria Quick Guide, P-03143 (PDF)
- Level IV Criteria Quick Guide, P-03144 (PDF)
- Statewide Performance Improvement Indicators, P-03364 (PDF)
Pre-review
- Level III Pre-Review Questionnaire (PRQ), F-47484 (Word)
- Level IV Pre-Review Questionnaire (PRQ), F-47484a (Word)
- TCF Classification Site Review Introduction PowerPoint Outline (PDF)
- Required documents checklist (PDF)
- Pediatric equipment checklist (PDF)
- Sample Facility Questions During Tour, P-03514 (PDF)
- Wis. Admin. Code ch. DHS 118 Frequently Asked Questions, P-03367 (PDF)
Pre-review questionnaire
- This is a living document that can be updated as needed.
- By typing rather than handwriting information, the document can be updated more easily.
- Several people should review the document for accuracy and spelling.
- It can be used as an orientation tool for new trauma coordinators or registrars.
Chart review
- Plan for the trauma medical director and trauma coordinator to attend the chart review.
- Select your charts in advance, as indicated in the TCF Classification Site Review Agenda (PDF).
- If printing your documents:
- Print the required documents and place in order in a designated folder. It is helpful to have them divided into sections (prehospital, emergency department, transfer, inpatient, etc.).
- Place all performance improvement documentation, such as checklists or multidisciplinary meeting minutes, pertaining to that issue in the patient-specific folder.
- If sharing your documents electronically:
- Ensure you have at least two individuals who are familiar with your system and charts available to assist each of the site reviewers with navigation of the folder. The electronic health record (EHR) should only be utilized upon request of the site reviewers.
- Ideally, export the items from the EHR and save the documents into a patient-specific folder.
- Ensure you have all sections of care (prehospital, emergency department, transfer, inpatient) clearly labeled within the specific patient's folder.
- Ensure you have all performance improvement documentation, such as checklists or multidisciplinary meeting minutes, pertaining to that issue within the specific patient's folder.
For more information, visit the Wisconsin Trauma Care Registry webpage.
When completing your facility's PRQ in preparation for your site visit, the reporting period should cover 12 months of data, but the data should not be older than 15 months from when the PRQ is submitted to DHS. Please review the following table to determine the appropriate PRQ reporting periods based on your facility's scheduled site visit. Your facility can select either option 1 or 2 based on your facility's preference. The PRQ must be submitted 45 days prior to the scheduled site visit.
| Month of Scheduled Site Visit (2024) | Option 1 Reporting Period | Option 2 Reporting Period |
|---|---|---|
| January | August 1, 2022–July 31, 2023 | September 1, 2022–August 31, 2023 |
| February | September 1, 2022–August 31, 2023 | October 1, 2022–September 30, 2023 |
| March | October 1, 2022–September 30, 2023 | November 1, 2022–October 31, 2023 |
| April | November 1, 2022–October 31, 2023 | December 1, 2022–November 30, 2023 |
| May | December 1, 2022–November 30, 2023 | January 1, 2023–December 31, 2023 |
| June | January 1, 2023–December 31, 2023 | February 1, 2023–January 31, 2024 |
| July | February 1, 2023–January 31, 2024 | March 1, 2023–February 28, 2024 |
| August | March 1, 2023–February 28, 2024 | April 1, 2023–March 31, 2024 |
| September | April 1, 2023–March 31, 2024 | May 1, 2023–April 30, 2024 |
| October | May 1, 2023–April 30, 2024 | June 1, 2023–May 31, 2024 |
| November | June 1, 2023–May 31, 2024 | July 1, 2023–June 30, 2024 |
| December | July 1, 2023–June 30, 2024 | August 1, 2023–July 31, 2024 |
When completing your facility's PRQ in preparation for your site visit, the reporting period should cover 12 months of data, but the data should not be older than 15 months from when the PRQ is submitted to DHS.
Review the following table to determine the appropriate PRQ reporting periods based on your facility's scheduled site visit. Your facility can select either option 1 or 2 based on your facility's preference. The PRQ must be submitted 45 days prior to the scheduled site visit.
| Month of Scheduled Site Visit (2025) | Option 1 Reporting Period | Option 2 Reporting Period |
|---|---|---|
| January | August 1, 2023–July 31, 2024 | September 1, 2023–August 31, 2024 |
| February | September 1, 2023–August 31, 2024 | October 1, 2023–September 30, 2024 |
| March | October 1, 2023–September 30, 2024 | November 1, 2023–October 31, 2024 |
| April | November 1, 2023–October 31, 2024 | December 1, 2023–November 30, 2024 |
| May | December 1, 2023–November 30, 2024 | January 1, 2024–December 31, 2024 |
| June | January 1, 2024–December 31, 2024 | February 1, 2024–January 31, 2025 |
| July | February 1, 2024–January 31, 2025 | March 1, 2024–February 28, 2025 |
| August | March 1, 2024–February 28, 2024 | April 1, 2024–March 31, 2025 |
| September | April 1, 2024–March 31, 2025 | May 1, 2024–April 30, 2025 |
| October | May 1, 2024–April 30, 2025 | June 1, 2024–May 31, 2025 |
| November | June 1, 2024–May 31, 2025 | July 1, 2024–June 30, 2025 |
| December | July 1, 2024–June 30, 2025 | August 1, 2024–July 31, 2025 |
Criteria highlights are intended to provide clarification to frequently asked questions or recently cited deficiencies. To receive the criteria highlights in your inbox, subscribe to our GovDelivery list.
Applicable to all level III and IV facilities, type 2 deficiency
- Criteria 2(o)
- Criteria 3(h)
- Criteria 14(i)
- Criteria 14(b) ED Boarding
- Criteria 14(b) Hospice
- Criteria 11(nm)
- Criteria 8(c)
Applicable to level III and IV facilities, type 1 deficiency
The following site review registry documents are intended for trauma program staff who are completing the pre-review questionnaire (PRQ) as supplemental guidance.
- PRQ Site Review Report Training
- How to Troubleshoot PRQ Reports
- 2023 Trauma Site Review Reports Job Aid Trauma Center Site Review Reports Job Aid 2023, P-03178 (PDF)
- 2023 Trauma Site Review PRQ Data Table Explanation Job Aid Site Review PRQ Data Table Explanations, P-03178 (PDF)
- 2023 Trauma Site Review Report Log Level III Facilities, P-03165 (PDF)
- 2023 Trauma Site Review Repot Log Level IV Facilities, P-03165A (PDF)
Waiver
Under Wis. Admin. Code DHS 118.04(5), DHS may grant a waiver of any non-statutory requirement under Wis. Admin. Code ch. DHS 118, upon written request, if DHS finds that strict enforcement of the requirement will create an unreasonable hardship for the trauma care facilities or the public in meeting the trauma care service needs of the facilities service area and that waiver of the requirement will not adversely affect the health, safety or welfare of patients or the general public.
Return this completed form, F-03282 (PDF) and necessary attachments by email to dhstrauma@dhs.wisconsin.gov or by the US Postal Service to: Waiver Request, Wisconsin Trauma Program, 1 W Wilson St., PO Box 2659, Madison, WI 53701-2659.