Section 640

Section 640.APPENDIX I Perinatal Reporting System Data Elements

1. Child's First Name

2. Child's Middle Name

3. Child's Last Name

4. Child's Suffix

5. AKA

6. Child's Date of Birth

7. Child's Time of Birth

8. Sex

A. Male

B. Female

C. Ambiguous

9. Race

A. White

B. Black

C. Asian

D. Other

10. Hispanic

A. Yes

B. No

C. N/A

11. Place of Birth

12. City of Birth

13. County of Birth

14. Mother's First Name

15. Mother's Middle Name

16. Mother's Last Name

17. Mother's Maiden Name

18. Mother's Social Security Number

19. Mother's Date of Birth

20. Mother's Street Number

21. Mother's Street Name

22. Mother's Street Direction

23. Mother's Street Type

24. Mother's Street Location

25. Mother's City

26. Mother's County

27. Mother's Zip Code

28. Mother's State

29. Mother's Telephone

30. Mother's Age

31. Mother's Birthplace

A. ________State

B. ________County

32. Mother of Hispanic Origin

A. Yes

Cuban

Mexican

Puerto Rico

B. No

33. Mother's Race

A. American Indian

B. Black

C. White

34. Mother's Education (specify highest grade completion)

35. Mother's Occupation

_________________

36. Mother's Business/Industry

37. Mother Employed During Pregnancy

A. Yes

B. No

C. Record Not Available

D. Not Stated

38. Martial Status

A. Married

B. Not Married

39. Father's Last Name

40. Father's Middle Name

41. Father's First Name

42. Father of Hispanic Origin

A. Yes

Cuban

Mexican

Puerto Rican

B. No

43. Father's Race

A. Indian American

B. Black

C. White

44. Father's Education (specify highest grade completed)

45. Father's Age

46. Father's Occupation

________________

47. Father's Business/Industry

__________________

48. Father Employed

A. Yes

B. No

C. Record N/A

D. Not Stated

49. Pregnancy History

50. Plurality (# this Birth)

If greater than 1, Birth Order of this Birth

51. Previous Live Births

52. Number Live Births Now Living

53. Number Live Births Now Dead

54. Date of Last Live Birth

55. Previous Terminations

56. Number of Other Terminations

57. Date of Last Other Termination

58. Date Last Normal Menses

59. Month Prenatal Care Began

60. Number of Prenatal Care Visits

61. 1 Minute APGAR Score

62. 5 Minute APGAR Score

63. Estimate of Gestation Weeks

64. Mother Transferred In Prior to Delivery

A. Yes

B. Name of Facility ________________ Location of

Facility ________________

C. No

65. Infant Transferred (Out)

A. Yes

B. Names of Facility ____________ Location of

Facility _____________

C. Transfer Code

D. No

66. Reporting Hospital

67. Reporting Hospital City

68. Tobacco Use During Pregnancy

A. Smoked during pregnancy

Average cigarettes per day

B. Stopped smoking during

C. Smoked during pregnancy

D. Does not smoke

E. Record N/A

F. Not Stated

69. Alcohol Use During Pregnancy

A. Yes

Average number drinks per day

B. No

C. Record N/A

D. Not Stated

70. Mother's Weight Gain

A. Yes

B. No

C. Record N/A

D. Not Stated

Pounds __________

71. Mother's Weight Loss

A. Yes

B. No

C. Record N/A

D. Not Stated

Pounds _________

72. Medical Risk Factors for this Pregnancy

A. Anemia

B. Cardiac Disease

C. Acute or Chronic Lung Disease

D. Diabetes

E. Genital Herpes

F. Hydramnios/Oligohydraminos

G. Hemoglobinapathy

H. Hypertension, Chronic

I. Hypertension, Pregnancy, related

J. Eclampsia

K. Incompetent Cervix

L. Previous Infant 4000 + Grams

M. Previous Preterm or SGA Infant

N. Renal Disease

O. Rh Sensitization

P. Uterine Bleeding

Q. None

R. Other, Specify

73. Obstetric Procedures

Aminocentesis

Electronic Fetal Monitoring

Internal

External

Both

Neither

Record N/A

Not Stated

Induction of Labor

Stimulation of Labor

K. Yes

Pitocin _____

Oxytocin _____

L. No

M. Record N/A

N. Not Stated

O. Tocolysis

P. Ultrasound

Q. None

R. Other, Specify

74. Complications of Labor and/or Delivery

A. Febrile

B. Meconium

C. Premature Rupture

D. Abruptio Placenta

E. Placenta Previa

F. Other Excessive bleeding

G. Seizures during labor

H. Precipitous labor

I. Prolonged labor

J. Dysfunctional labor

K. Breech/Malpresentation

L. Cephalopelvic Disportion

M. Cord Prolapse

N. Anesthetic complications

O. Fetal Distress

P. None

Q. Other, Specify

75. Method of Delivery

A. Spon. Vaginal

B. Mid – Low Forceps

C. Vacuum Extraction

D. Vaginal Breech

E. C. Section Primary

F. C. Section Repeat

G. Other type

H. Record N/A

I. Not Stated

J. Vaginal After Previous C Section

K. Other C Section

76. Abnormal Conditions of Newborn

77. Anemia

78. Birth Injury

79. Fetal Alcohol Syndrome

80. Hyaline Membrane Disease

81. Meconium Aspiration Syndrome

82. Assisted Ventilation > 30 min.

83. Assisted Ventilation = 30 min.

84. Seizures

85. None

86. Other Specify

87. Congenital Anomolies of Child

88. Anacephalus

89. Spina Bifida/Meningocele

90. Hydrocephalus

91. Microcephalus

92. Other CNS Anomalies Specify ____________

93. Heart Malformations Specify _____________

94. Other Circulatory/Respiratory Anomalies Specify ____________

95. Rectal Atresia/Stenosis

96. Tracheoesophageal Fistula/Esophageal Atresia

97. Omphalocele/Gastrochisis

98. Other Gastrointestinal Anomaly

99. Malformed Genitalia

100. Renal Agenesis

101. Other Urogenital Anomaly Specify ____________

102. Cleft Lip/Palate Specify ____________

103. Polydactyly/Syndactyly/Adctyly

104. Club Foot

105. Diaphragmatic Hernia

106. Other Musuloskeletal/Integumental Anomaly

107. Downs Syndrome

108. Other Chromosomal Anomaly ____________ Specify

109. None

110. Other, Specify ____________

111. Transfusion

112. Anesthesia

A. Local/Pudenal

B. Regional

C. General

113. Umbilical Cord Blood Gases Tested

A. Yes

B. No

114. Small for Gestational Age

115. Infection of Newborn Acquired Before Birth

116. Infection of Newborn Acquired During Birth

117. Infection of Newborn Acquired After Birth

118. Hereditary Hemolytic Anemias

119. Hemolytic Diseases of the Newborn

120. Due to Rh Incompatibility Only

121. Due to ABO Incompatibility

122. Due to Other Causes

123. Drug Toxicity or Withdrawal

A. Yes, Specify ____________

B. No

124. Highest Bilirubin

A. Total ____________

125. Admit to Designated Patient Unit

A. Yes

B. No

126. Genetic Screenings Conducted

127. Rh Determination

A. Mother's Blood Type _______ Rh Factor _______

Immune Globulin Given

Yes

128. Hepatitis B – Surface Antigen

A. Positive

B. Negative

129. Non-Obstetrical Infections

A. Syphilis

B. Gonorrhea

C. Rubella

D. Other

130. Obstetrical Infections

A. Antepartum

Amnionitis/Chioramnionitis

Urinary Tract Infection

B. Postpartum

Endometritis

Infection of Wound

Urinary Tract Infection

131. Mother admitted with 72 hours of delivery

A Precipitous Delivery

B Planned Home Birth

132. Drug Use During Pregnancy

A. Cocaine

B. Heroin

C Marijuana

D. Other Street Drug(s)

E None

F. Record N/A

G. Not Stated

133. Transfusion

134. Prenatal Screening Conducted for

A. Gestational Diabetes

(Blood Glucose Tolerance Test)

B. Congenital/Birth Defects

A. Maternal Alpha Feta Protein

B. Chromosomal

C. Other

135. Number of Days Maintained on Ventilation Before Transfer to Level III Center-Days

136. Prenatal Ultrasound

A. Yes

B. No

C. Record N/A

D. Not Stated

137. Chorionic Villus Sampling

138. Were Newborn Screening Tests Conducted?

A. Yes

B. No

139. Mother Transferred Out to Another Hospital After Delivery Destination Hospital Code

140. Mother Transferred From Emergency Room

141. Infant Transferred In Transfer Code

142. Consult Perinatal Center

143. Infant Maternal

A.	A.	Yes, W/Transfer

B.	B.	Yes, No Transfer

C.	C.	No Consultation

D.	D.	Not Stated

144. Mother Died In Hospital

145. Fetal Death

146. Infant Died in Hospital

147. Extrauterine Pregnancy

148. Ectopic Pregnancy

149. Admission Date – Infant

150. Admission Date – Maternal

151. Discharge Date – Infant

152. Discharge Date – Maternal

153. Payment Method

A. Yes

Medicaid

Medicaid HMO

HMO

Medicare

CHAMPUS

Title V

Health Ins.

Self Pay

Record N/A

Not Stated

Health Ins/$/

Other, Specify __________

B. No

154. Were prenatal records available prior to delivery?

A. Yes

B. No

155. Maternal Diagnosis (Specify up to 8 Diagnoses)

156. Mother's Medical Record Number _________________

157. Infant Diagnoses (Including Congenital Anomalies); Specify up to 8 diagnosis

158. Infant Released to:

A. Home

B. Other Hospital	Name and Location

C. Long Term Care	Name and Location

D. Other Child Care Agency	Name and Location

159. Infant Patient ID

160. Infant Medical Record Number __________________

161. Referrals

A. Community Social Services

B. DSCC

C. DCFS

D. Other, Specify _________________

E. None

F. Early Intervention program

G. Other _______________

162. Feedings

163. Breast fed

164. Bottle

165. Tube

166. Formula

167. Frequency

168. Amount

169. Infant Medications

170. Birth Weight

171. Birth Head Circumference

172. Birth Length

173. Discharge Weight

174. Discharge Head Circumference

175. Discharge Length

176. Infant Discharge Treatment

177. Other Concerns

178. RN Contact at Hospital – Phone Number

179. Relative/Friend

180. Relationship

181. Address/Phone #

182. Family informed of LHN Visit

A. Yes

B. No

183. Primary Care Physician's Name –

184. Mother Gravida Para F_ P_ A_ L_

185. Signature

186. Title

187. Report Date

188. Other Infant Diagnoses

189. Congenital Syphilis

190. Hypothyroidism

191. Adrenogenital Syndrome

192. Inborn Errors of Metabolism

193. Cystic Fibrosis

194. Immune Deficiency Disorder

195. Leukemia

196. Constitutional Aplastic Anemia

197. Coagulation Defects

198. Neurofibromatosis

199. Retinopathy of prematurity

200. Chorioretinitis

201. Strabismus

202. Endocardial Fibroelastosis

203. Occlusion of Cerebral Arteries

204. Intrauterine Growth Retardation

205. Cerebral Lipidoses