Section 640.90  Perinatal Reporting System

a)         Purpose

            The Department will maintain a Perinatal Reporting System to follow selected high-risk perinatal patients, to insure that those patients are assessed at appropriate intervals, receive intervention as needed, and are referred for needed support services.

b)         Identification and Referral of High-risk Maternal Patients.

1)         Each designated Perinatal Center and Level III facility which provides obstetrical care shall establish criteria and procedures for identifying high-risk pregnant and postpartum patients. A statement describing such criteria and procedures shall be on file and shall be provided to the Department on request.

2)         Each designated Perinatal Center and Level III facility shall prepare and distribute a Maternal Discharge Record (see Appendix C), to be provided by the Department, for each high-risk pregnancy or postpartum patient treated in the facility who requires public health nursing follow-up. If a patient is readmitted during the same or subsequent pregnancies and is deemed to be high-risk, another Maternal Discharge Record shall be prepared and distributed if public health nursing follow-up is needed.

3)         The hospital's Perinatal Review Committee established pursuant to Section 640.70, or other committee established for the purpose of internal quality control or medical study for the purpose of reducing morbidity or mortality or improving patient care, shall collect and submit the required information to the Department. These data will be considered confidential under Section 8-2101 of the Code of Civil Procedure [735 ILCS 5/8-2101].

4)         The Maternal Discharge Record shall be completed and distributed within seven days after the patient's discharge from the facility. Instructions for proper completion of the Maternal Discharge Record are contained in Appendix C. Additional pages may be attached when there is insufficient space on the form for all needed information.

5)         Copies of the Maternal Discharge Record shall be distributed as follows:

A)        The original form (white copy) of the Maternal Discharge Record shall be sent to the Department of Public Health, 535 West Jefferson, Springfield, Illinois 62761;

B)        The yellow copy shall be sent to the Local Health Department or other local health agency designated by the Department to provide follow-up services in the county or area in which the patient resides;

C)        The pink copy shall be retained by the reporting facility.

6)         The hospital staff is encouraged to contact the designated local health agency by telephone when there is a need for additional information to be communicated to the local health nurse, or when a pre-discharge visit by the local health nurse is needed.

7)         The Department will provide to the hospitals a list of Local Health Departments and other local health agencies designated to provide follow-up services to high-risk maternal patients. The list will be updated as needed, at least annually.

c)         Identification of Perinatal Patients

1)         The Department requires that all Illinois hospitals licensed to provide obstetrical and newborn services report information on all perinatal patients. The Department requests, but does not require, reports on perinatal patients from hospitals outside Illinois, except the St. Louis perinatal centers, and hospitals maintained by the Federal Government or other governmental agencies within the United States.

2)         Each hospital will prepare a Perinatal Report record (see Appendix H) to be provided by the Department for patients meeting one of the following conditions:

A)        Live-birth.

B)        Diagnosed prior to discharge from newborn hospitalization as a perinatal or neonatal death.

            AGENCY NOTE: Women that present with spontaneous abortion, ectopic pregnancy or hydatid mole are perinatal patients and must be reported. In addition, the products of induced abortions shall not be reported to the Perinatal Reporting System.

            AGENCY NOTE: Fetal death (gestation greater than 20 weeks) is considered a reportable perinatal outcome and will be included in the Perinatal Reporting System. However, fetal deaths do not have to be reported through the Perinatal Reporting System, because these deaths are already reported and compiled in the Departments's Vital Records database.

3)         Every hospital shall provide representatives of the Department with access to information from all medical, pathological, and other pertinent records and logs related to reportable registry information. The mode of access and the time during which this access will be provided shall be by mutual agreement between the hospital and the Department.

4)         The Perinatal Reporting System also will be complemented with information from the Department's Vital Records live birth database under the Vital Records Act[410 ILCS 535], the Adverse Pregnancy Outcomes Reporting System under the Illinois Health and Hazardous Substances Registry Act [410 ILCS 525] and other Maternal and Child Health Reports and submissions.

5)         The Perinatal Reporting System consists of two forms of reporting. This reporting shall be on the forms provided by the Department or through electronic means that meets the exact specifications of the Department's data processing system. Complete perinatal reporting information must be reported to the Department within 14 days after infant discharge, regardless of the method of reporting.

6)         The Perinatal Report record shall be distributed in the following manner:

A)        Two copies of the Perinatal Reporting System record must be sent to the Department of Public Health's Office of Epidemiology and Health Systems Development, 605 West Jefferson, Springfield, Illinois 62761.

B)        A pink copy may be retained by the reporting facility.

C)        A copy must be forwarded to the Local Health Nurse.

D)        A copy must be forwarded to the Primary Care Physician.

d)         Report of Local Health Nurse

1)         The Local Health Department or other designated local health agency providing follow-up services to high-risk infants shall prepare and distribute a Report of Local Health Nurse for each visit made; a Report shall also be distributed when a case is closed without a visit.

2)         Copies of the Report of Local Health Nurse shall be distributed as follows:

A)        The original form (white copy) of the Report of Local Health Nurse shall be sent to the Department of Public Health, 535 West Jefferson, Springfield, IL 62761.

B)        The canary copy shall be sent to the hospital which referred the patient for follow-up services.

C)        The pink copy shall be retained at the appropriate Local Health Nurse Agency.

D)        The goldenrod copy shall be sent to the patient's primary care physician.

3)         The Local Health Department or other designated local health agency providing follow-up services to high-risk pregnant and postpartum women should send a copy of the progress notes to the referring hospital.

e)         Availability of Information

1)         The patient and facility-identifying information submitted to the Department or local health agency under the Act and this Part shall be privileged and confidential and shall not be available for disclosure, inspection or copying under the Freedom of Information Act or the State Records Act, except as described in this Section. These data shall also be considered confidential under Section 8-2101 of the Code of Civil Procedure.

2)         Aggregate summary and reports of follow-up activities may be provided upon request to hospitals, to Perinatal Centers, and to the local health agency designated by the Department to provide follow-up services to the patients. Such reports may contain information provided by the referring hospital and information provided by the follow-up agency. Patient or facility specific data provided to the appropriate designee under this Section is confidential and shall be handled in accordance with the provisions of the Illinois Health Statistics Act [410 ILCS 520] and Section 9 of the Hospital Licensing Act [210 ILCS 85/9]. These data shall also be considered confidential under Section 8-2101 of the Code of Civil Procedure [735 ILCS 5/8-2101].

3)         All reports issued by the Department in which the data is aggregated so that no patient or reporting facility may be identified shall be available to the public pursuant to the Department's Freedom of Information rules (2 Ill. Adm. Code 1126) and the Freedom of Information Act [5 ILCS 140].

f)          Quality Assurance and Continuous Quality Improvement

1)         Reporting facilities (i.e., hospitals, Local Health Departments, managed care entities (MCE), and designated local health agencies) shall be subject to review by the Department to assess the timeliness, correctness and completeness of the reports submitted by the facility.

2)         Reporting facilities (i.e., hospitals, Local Health Departments, managed care entities (MCE), and designated community health agencies) shall supply to the Department at the Department's request additional information when needed to confirm the accuracy of reports previously submitted, or to clarify information previously submitted. The Department shall not request data that are more than two years old.

3)         Monthly reports will be compiled by the Department, listing all hospital referrals to each health department/agency.  The reports will be used for audits and assistance to health departments.

4)         Managed Care Entities must submit their Quality Assurance Plan (QAP) to the Department for review and use in state-wide Quality Improvement in Perinatal program efforts.

(Source:  Amended at 24 Ill. Reg. 12574, effective August 4, 2000)