TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH
SUBCHAPTER l: MATERNAL AND CHILDCARE
PART 640 REGIONALIZED PERINATAL HEALTH CARE CODE
SECTION 640.APPENDIX I PERINATAL REPORTING SYSTEM DATA ELEMENTS


 

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.         Child of Hispanic Origin

 

            A.        Yes

                        Cuban

            Mexican

            Puerto Rican

           

            B.        No

 

10.       Race

 

A.        Asian

 

B.        Black

 

C.        Caucasian

 

D.        Native American

 

E.         Other

 

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 Rican

 

B.        No

 

33.       Mother's Race

 

A.        Asian

 

B.        Black

 

C.        Caucasian

 

D.        Native American

 

E.         Other

 

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

 

35.       Mother's Occupation

_________________

 

36.       Mother's Business/Industry

 

37.       Mother Employed During Pregnancy

 

A.        Yes

 

B.        No

 

C.        Record Not Available (N/A)

 

D.        Not Stated

 

38.       Marital 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.        Asian

 

B.        Black

 

C.        Caucasian

 

D.        Native American

 

E.         Other

 

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 of 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 Number of Gestation Weeks

 

64.       Mother Transferred In Prior to Delivery

 

A.        Yes

 

B.        Name of Hospital ________________

Location of Hospital ________________

 

C.        No

 

65.       Infant Transferred (Out)

 

A.        Yes

 

B.        Name of Hospital ____________

Location of Hospital _____________

 

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 pregnancy

 

C.        Does not smoke

 

D.        Record N/A

 

E.         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

Pounds ______

 

B.        No

 

C.        Record N/A

 

D.        Not Stated

 

71.       Mother's Weight Loss

 

A.        Yes

Pounds ______

 

B.        No

 

C.        Record N/A

 

D.        Not Stated

 

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/Oligohydramnios

 

G.        Hemoglobinapathy

 

H.        Hypertension, Chronic

 

I.          Hypertension, Pregnancy-related

 

J.          Eclampsia

 

K.        Incompetent Cervix

 

L.         Previous Infant 4000 + Grams

 

M.        Previous Preterm or Small-for-Gestational-Age (SGA) Infant

 

N.        Renal Disease

 

O.        Rh Sensitization

 

P.         Uterine Bleeding

 

Q.        None

 

R.        Other, Specify

 

73.       Obstetric Procedures

 

A.        Amniocentesis

 

B.        Electronic Fetal Monitoring

Internal

External

Both

Neither

Record N/A

Not Stated

 

C.        Induction of Labor

 

D.        Stimulation of Labor

Yes

Pitocin _____

Oxytocin _____

No

Record N/A

Not Stated

 

E.         Tocolysis

 

F.         Ultrasound

 

G.        None

 

H.        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.        Spontaneous Vaginal

 

B.        Mid – Low Forceps

 

C.        Vacuum Extraction

 

D.        Vaginal Breech

 

E.         Caesarean Section Primary

 

F.         Caesarean Section Repeat

 

G.        Other Type

 

H.        Record N/A

 

I.          Not Stated

 

J.          Vaginal Birth After Previous Caesarean Section (VBAC)

 

K.        Other Caesarean 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.       Human Immunodeficiency Virus (HIV)

 

86.       Other, Specify

 

87.       Congenital Anomolies of Newborn

 

88.       Anencephalous

 

89.       Congenital Syphilis

 

90.       Hypothyroidism

 

91.       Adrenogenital Syndrome

 

92.       Inborn Errors of Metabolism

 

93.       Cystic Fibrosis

 

94.       Immune Deficiency Disorder

 

95.       Retinopathy of Prematurity

 

96.       Chorioretinitis

 

97.       Strabismus

 

98.       Intrauterine Growth Restriction

 

99.       Cerebral Lipidoses

 

100.     Spina Bifida/Meningocele

 

101.     Hydrocephalus

 

102.     Microcephalus

 

103.     Other CNS Anomalies, Specify ____________

 

104.     Heart Malformations, Specify _____________

 

105.     Other Circulatory/Respiratory Anomalies, Specify ____________

 

106.     Rectal Atresia/Stenosis

 

107.     Tracheoesophageal Fistula/Esophageal Atresia

 

108.     Omphalocele/Gastrochisis

 

109.     Other Gastrointestinal Anomaly

 

110.     Malformed Genitalia

 

111.     Renal Agenesis

 

112.     Other Urogenital Anomaly, Specify ____________

 

113.     Cleft Lip/Palate, Specify ____________

 

114.     Polydactyly/Syndactyly/Adactyly

 

115.     Club Foot

 

116.     Diaphragmatic Hernia

 

117.     Other Musculoskeletal/Integumental Anomaly

 

118.     Down's Syndrome

 

119.     Other Chromosomal Anomaly, Specify ____________

 

120.     None

 

121.     Other, Specify ____________

 

122.     Transfusion

 

123.     Anesthesia

 

A.        Local/Pudenal

 

B.        Regional

 

C.        General

 

124.     Umbilical Cord Blood Gases Tested

 

A.        Yes

 

B.        No

 

125.     Small-for-Gestational-Age (SGA)

 

126.     Infection of Newborn Acquired Before Birth

 

127.     Infection of Newborn Acquired During Birth

 

128.     Infection of Newborn Acquired After Birth

 

129.     Hereditary Hemolytic Anemias

 

130.     Hemolytic Diseases of the Newborn

 

131.     Due to Rh Incompatibility Only

 

132.     Due to ABO Incompatibility

 

133.     Due to Other Causes

 

134.     Drug Toxicity or Withdrawal

 

A.        Yes, Specify ____________

 

B.        No

 

135.     Highest Bilirubin, Total ________

 

136.     Admit to Designated Patient Unit

 

A.        Yes

 

B.        No

 

137.     Genetic Screenings Conducted

 

138.     Rh Determination

 

A.        Mother's Blood Type _______ Rh Factor _______

Immune Globulin Given

 

B.        Yes

 

C.        No

 

139.     Hepatitis B – Surface Antigen

 

A.        Positive

 

B.        Negative

 

140.     Non-Obstetrical Infections

 

A.        Syphilis

 

B.        Gonorrhea

 

C.        Rubella

 

D.        Other

 

141.     Obstetrical Infections

 

A.        Antepartum

Amnionitis/Chioramnionitis

Urinary Tract Infection

 

B.        Postpartum

Endometritis

Infection of Wound

Urinary Tract Infection

 

142.     Mother admitted within 72 hours after delivery

 

A.        Precipitous Delivery

 

B.        Planned Home Birth

 

143.     Drug Use During Pregnancy

 

A.        Cocaine

 

B.        Heroin

 

C.        Marijuana

 

D.        Other Street Drugs

 

E.         None

 

F.         Record N/A

 

G.        Not Stated

 

144.     Transfusion

 

145.     Prenatal Screening Conducted for

 

A.        Gestational Diabetes

(Blood Glucose Tolerance Test)

 

B.        Congenital/Birth Defects

 

A.        Maternal Alpha Feta Protein

 

B.        Chromosomal

 

C.        Other

 

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

 

147.     Prenatal Ultrasound

 

A.        Yes

 

B.        No

 

C.        Record N/A

 

D.        Not Stated

 

148.     Chorionic Villus Sampling

 

149.     Were Newborn Screening Tests Conducted?

 

A.        Yes

 

B.        No

 

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

 

151.     Mother Transferred From Emergency Room

 

152.     Infant Transferred In Transfer Code

 

153.     Consult Administrative Perinatal Center or Another Level III

 

154.     Infant                          Maternal

 

A.

A.

Yes, with Transfer

 

 

 

B.

B.

Yes, No Transfer

 

 

 

C.

C.

No Consultation

 

 

 

D.

D.

Not Stated

 

155.     Mother Died In Hospital

 

156.     Fetal Death

 

157.     Infant Died in Hospital

 

158.     Extrauterine Pregnancy

 

159.     Ectopic Pregnancy

 

160.     Admission Date – Infant

 

161.     Admission Date – Maternal

 

162.     Discharge Date – Infant

 

163.     Discharge Date – Maternal

 

164.     Payment Method

 

A.        Yes

 

Medicaid

Medicaid HMO

HMO

Medicare

CHAMPUS

Title V

Health Insurance

Self Pay

Not Stated

Other, Specify __________

 

B.        No

 

165.     Were prenatal records available prior to delivery?

 

A.        Yes

 

B.        No

 

166.     Maternal Diagnosis (Specify up to 8 Diagnoses)

 

167.     Mother's Medical Record Number _________________

 

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

 

169.     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

 

 

 

 

 

170.     Infant Patient ID

 

171.     Infant Medical Record Number __________________

 

172.     Referrals

 

A.        Community Social Services

 

B.        Division of Specialized Services for Children (DSCC)

 

C.        Department of Healthcare and Family Services (HFS)

 

D.        Department of Children and Family Services (DCFS)

 

E.         Other, Specify _________________

 

F.         None

 

G.        Early Intervention program

 

H.        Other _______________

 

173.     Feedings

 

174.     Breast Fed

 

175.     Bottle

 

176.     Tube

 

177.     Formula

 

178.     Frequency

 

179.     Amount

 

180.     Infant Medications

 

181.     Birth Weight

 

182.     Birth Head Circumference

 

183.     Birth Length

 

184.     Discharge Weight

 

185.     Discharge Head Circumference

 

186.     Discharge Length

 

187.     Infant Discharge Treatment

 

188.     Other Concerns

 

189.     RN Contact at Hospital – Phone Number

 

190.     Relative/Friend

 

191.     Relationship

 

192.     Address/Phone #

 

193.     Family Informed of Local Health Nurse Visit

 

A.        Yes

 

B.        No

 

194.     Primary Care Physician's Name –

 

195.     Mother Gravida Para F_ P_ A_ L_

 

196.     Signature

 

197.     Title

 

198.     Report Date

 

(Source:  Amended at 35 Ill. Reg. 2583, effective January 31, 2011)