I Perinatal Reporting System Data Elements

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.         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.        Hemoglobinopathy 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 Anomalies 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/Gastroschisis 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/ Pudendal 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/Chorioamnionitis 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