State of Illinois

Department of Public Health

MATERNAL DISCHARGE RECORD

PERINATAL TRACKING SYSTEM

ONLY DISCHARGING HOSPITAL COMPLETES.

Medicaid Recipient #

COMPLETE ONLY ON PATIENTS REQUIRING REFERRAL

Medicaid Pending

 Yes

 No

*Required

Social Security #

REFERRING HOSPITAL AND CITY*

CODE*

MED. REC #*

CORNERSTONE #

C L I E N T

DATE OF ADMISSION*

RACE*

HISPANIC*

COUNTY OF RESIDENCE*

CODE*

 WHITE

 BLACK

 YES

 NO

 ORIENTAL

 OTHER

PATIENT'S LAST NAME*

FIRST NAME*

M.I.

DATE OF BIRTH*

HUSBAND'S LAST NAME

FIRST NAME

PATIENT'S MAIDEN NAME

MARITIAL STATUS

PATIENT'S TELEPHONE NUMBER

 MARRIED

 UNMARRIED

PATIENT'S STREET ADDRESS – APT. NUMBER*

CITY

STATE

ZIP CODE

GRAVIDA*

PARA*

BLOOD TYPE

HBsAG STATUS

EDC*

PRENATAL CARE BEGAN

PRENATAL VISITS

_______

F___P___A___L___

___GRP____RH

 POS.  NEG.

___/___/___

__________WKS. GEST.

______# OF VISITS

M E D I C A L

REPRODUCTIVE HISTORY CHECK

REASONS FOR REFERRAL

APPROPRIATE NUMBERS

1. ____

ABRUPTIO – CHRONIC

17. ____

INCOMPETENT CERVIX

1. ____

C/SECTION WITH COMPLICATIONS

2. ____

ALCOHOL ABUSE

18. ____

INTRAUTERINE GROWTH RESTRICTION

2. ____

INFANT WITH CONGENITAL

3. ____

ASTHMA

19. ____

MULTIPLE GESTATION

ANOMALIES

4. ____

CANCER

20. ____

NO PRENATAL CARE

3. ____

NEONATAL DEATH

5. ____

CHRONIC DISEASE (SPECIFY)_____________

21. ____

PRE-ECLAMPSIA

4. ____

SIDS

6. ____

CHRONIC RENAL DISEASE

22. ____

REMATURE LABOR

5. ____

STILLBORN

7. ____

CONVULSIVE DISORDER`

23. ____

PREMATURE RUPTURE OF MEMBRANE

6. ____

OTHER (SPECIFY)

8. ____

DIABETES

24. ____

PREVIA

9. ____

DRUG ABUSE (SPECIFY)__________________

25. ____

PSYCHIATRIC DISORDER

____________________________________________

10.____

FETAL ANOMALY

26. ____

PULMONARY EMBOLUS

11.____

FETAL DEATH IN UTERO

27. ____

PYELONEPHRITIS

12.____

HEART DISEASE

28. ____

RH SENSITIZATION

____________________________________________

13.____

HEMOGLOBINOPATHY

29. ____

SEXUALLY TRANSMITTED DISEASE

INCLUDING SICKLE CELL

30. ____

SIGNIFICANT SOCIAL PROBLEMS

14.____

HYPEREMESIS

31. ____

TEEN PREGNANCY

15.____

HYPERTENSION

32. ____

THROMBO-EMBOLIC DISEASE

S O C I A L

16.____

IDIOPATHIC THROMBOCYTOPENIA

33. ____

VIOLENCE, FAMILY

PURPURA (ITCP)

34. ____

OTHER______________________________

DISCHARGE  DATE*

BLOOD PRESSURE

HEIGHT

WEIGHT (CURRENT)_______(lbs)

FAMILY PLANNING*

________/________

FT.____IN.____

 N/A

 REFERRED

 BEGAN

 NOT INTERESTED

PATIENT DELIVER

TYPE & DATE OF DELIVERY*

WAS INFANT AT HIGH RISK?*

INFANTS CONDITION

DURING THIS

 VAGINAL

 C-SECTION

SEX

 Male

 Female

ADMISSION?*

 OTHER___________________

 YES

 NO

 YES

 NO

DATE ____/____/____

BIRTH WEIGHT*_____(gms)

APGARS___/___

MAJOR TREATMENT OF MOTHER DURING HOSPITALIZATION & DISCHARGE TREATMENT/DIAGNOSIS/MEDICATIONS

F O L L O W   U P

OTHER CONCERNS:

PHYSICIAN PROVIDING FOLLOW-UP CARE:* (INC. ADDRESS & PHONE #)

HOSPITAL NURSE CONTACT

TELEPHONE

REFERRAL TO COMMUNITY

IF YES TO:

SERVICES*

 WIC

 HOME HEALTH

 SOCIAL SERVICE AGENCY

 PRENATAL ED

 YES

 NO

 MENTAL HEALTH

 DCFS

 OTHER (PLEASE SPECIFY)___________________________________

CONTACT PERSON'S NAME

RELATIONSHIP TO PATIENT*

TELEPHONE NUMBER*

(______)___________________________

STREET ADDRESS

CITY

STATE

ZIP CODE

2^ND CONTACT PERSON'S NAME

RELATIONSHIP TO PATIENT

TELEPHONE NUMBER*

(______)___________________________

PATIENT INFORMED OF PUBLIC HEALTH

PUBLIC HEALTH NURSE AGENCY NAME

CODE

ADDRESS

NURSE VISIT?

 YES

 NO

SEND ORIGINALS:

DEPARTMENT OF PUBLIC HEALTH

535 WEST JEFFERSON

SIGNATURE*______________________________

SPRINGFIELD, IL  62761

COPIES:

YELLOW – LOCAL HEALTH NURSE

PINK – FACILITY

DATE*____________________________________

IL444-4210 (N-10-98)