Study ID Number _____________________
Labor and Delivery Medical Record Abstraction Form
This form should be used for abstraction of medical records from all labor and delivery care providers seen during index pregnancy.
A single abstraction form should be used for all relevant providers.
Below list all providers that contributed data to this form.
OF NOTE: It is NOT necessary to indicate the specific provider record source for each individual data item on this form. It will be too cumbersome to try and detail exactly which record(s) provided which data. Hopefully, in most cases if the same information is provided in multiple different provider records, it will be consistent and complimentary. However, there might be cases in which conflicting information is presented in 2 different records. Use the data available to make your best judgment about the correct information and then add a comment providing details of the conflict between provider sources.
CONTRIBUTING PROVIDERS |
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A.1. Name of Provider/Hospital |
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A.2. Street Address |
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A.3. City |
A.4. State |
A.5. Zip Code |
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ABSTRACTION LOG |
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A.6. Date __ __/__ __/__ __ __ __ |
A.7. Date __ __/__ __/__ __ __ __ |
A.8. Date __ __/__ __/__ __ __ __ |
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A.6.1 to A.6.8 Time (*use military time)
Start __ __ : __ __ Stop __ __: __ __ Start __ __ : __ __ Stop __ __: __ __ Start __ __ : __ __ Stop __ __: __ __ |
A.71 to A.7.8 Time (*use military time)
Start __ __ : __ __ Stop __ __: __ __ Start __ __ : __ __ Stop __ __: __ __ Start __ __ : __ __ Stop __ __: __ __ |
A.8.1 to A.8.8 Time (*use military time)
Start __ __ : __ __ Stop __ __: __ __ Start __ __ : __ __ Stop __ __: __ __ Start __ __ : __ __ Stop __ __: __ __ |
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A.9. Date __ __/__ __/__ __ __ __ |
A.10. Date __ __/__ __/__ __ __ __ |
A.11. Date __ __/__ __/__ __ __ __ |
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A.9.1 to A.9.8 Time (*use military time)
Start __ __ : __ __ Stop __ __: __ __ Start __ __ : __ __ Stop __ __: __ __ Start __ __ : __ __ Stop __ __: __ __ |
A.10.1 to A.10.8 Time (*use military time)
Start __ __ : __ __ Stop __ __: __ __ Start __ __ : __ __ Stop __ __: __ __ Start __ __ : __ __ Stop __ __: __ __ |
A.11.1 to A.11.8 Time (*use military time)
Start __ __ : __ __ Stop __ __: __ __ Start __ __ : __ __ Stop __ __: __ __ Start __ __ : __ __ Stop __ __: __ __
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B.1. Name of Provider/Hospital |
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B.2. Street Address |
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B.3. City |
B.4. State |
B.5. Zip Code |
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ABSTRACTION LOG |
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B.6. Date __ __/__ __/__ __ __ __ |
B.7. Date __ __/__ __/__ __ __ __ |
B.8. Date __ __/__ __/__ __ __ __ |
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B.6.1 to B.6.8 Time (*use military time)
Start __ __ : __ __ Stop __ __: __ __ Start __ __ : __ __ Stop __ __: __ __ Start __ __ : __ __ Stop __ __: __ __
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B.71 to B.7.8 Time (*use military time)
Start __ __ : __ __ Stop __ __: __ __ Start __ __ : __ __ Stop __ __: __ __ Start __ __ : __ __ Stop __ __: __ __
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B.8.1 to B.8.8 Time (*use military time)
Start __ __ : __ __ Stop __ __: __ __ Start __ __ : __ __ Stop __ __: __ __ Start __ __ : __ __ Stop __ __: __ __
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B.9. Date __ __/__ __/__ __ __ __ |
B.10. Date __ __/__ __/__ __ __ __ |
B.11. Date __ __/__ __/__ __ __ __ |
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B.9.1 to B.9.8 Time (*use military time)
Start __ __ : __ __ Stop __ __: __ __ Start __ __ : __ __ Stop __ __: __ __ Start __ __ : __ __ Stop __ __: __ __
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B.10.1 to B.10.8 Time (*use military time)
Start __ __ : __ __ Stop __ __: __ __ Start __ __ : __ __ Stop __ __: __ __ Start __ __ : __ __ Stop __ __: __ __
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B.11.1 to B.11.8 Time (*use military time)
Start __ __ : __ __ Stop __ __: __ __ Start __ __ : __ __ Stop __ __: __ __ Start __ __ : __ __ Stop __ __: __ __
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A. IDENTIFYING INFORMATION No information for any item in section |
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2. Study ID# |
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3. Maiden Name |
4. AKA
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5. Mother’s DOB |
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6. Street Address (from L&D chart)
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7. City |
8. State |
9. Zip Code
_ _ _ _ _-_ _ _ _
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10.Place of Delivery
1. Hospital (enter Name in 11) 2. Car (Skip to ) 3. Ambulance (Skip to ) 4. Parking Lot (Skip to ) 5. Home (Skip to ) 6. Work (Skip to ) 7. Other, specify ________ 88 IL 99 NR
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11. Delivery Hospital Name
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12. Hospital Street Address
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Comments:
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Sections B-N: How to Document Various Types of Missing Information
A. No information -- entire section
Each section of each form will include either one or two universal missing check boxes. If either are checked, no further data are recorded for the entire section.
1. No information for any item in section
Checked if:
No relevant tests or procedures appear to have been ordered by any contributing medical care providers; and/or
No information was recorded for relevant health status, medical conditions, medications.
2. Test/procedure for one or more items in section indicated but no information on dates, results, etc.
(will only apply to certain sections as indicated)
B. Information available for one or more items within a section BUT no information for selected items
If there is information in the chart for one or more items in a given section on a given abstraction form, all pertinent data should be recorded. However, there is still the possibility that there will be missing data within these sections. Three types of missing data codes are recognized:
NA – NOT APPLICABLE (for use with certain items such as those with skip patterns and those for which multiple tests/procedures/etc. might have been performed and all are requested in abstraction form. After last relevant item is recorded, the subsequent item on abstract form is NA to indicate the end of reporting).
IL -- NOT LEGIBLE (self-explanatory)
NR – NO info in RECORD (“true missing” There should be information for an item, but it cannot be located.)
The following coding schemes will be applied to code these 3 types of missing:
Categorical variables with a finite coding scheme
NA
IL
99 NR
Dates and times – these may be completely missing or partially missing.
Data entry format is __ __/__ __/__ __ __ __ and __ __:__ __
For dates and time (military hours and minutes)
For day, month, hours, and minutes, enter 77, 88, or 99 as appropriate
For year the enter 7777, 8888, or 9999 as appropriate
Thus, these can be completely missing or mixed with valid data such as:
03/99/2003 and 10:88
Continuous/open ended data items: Since it will be overly burdensome to develop and employ a missing data scheme which individually considers each data item and the appropriate number of digits for missing values use the alpha codes for missing in these instances:
NA, IL, or NR
B. ADMISSION THAT LED TO DELIVERY No information for any item in section |
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__ __/__ __ /__ __ __ __
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2. Admit time
_ _ : _ _ |
3. Delivery date
__ __/__ __ /__ __ __ __
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4. Delivery time
_ _ : _ _
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5. Discharge date
__ __/__ __ /__ __ __ __
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6. Admitting Diagnoses
6a. DX1: __________________________________________________ 77 NA 88 IL 99 NR
6b. DX2: __________________________________________________ 77 NA 88 IL 99 NR
6c. DX3: __________________________________________________ 77 NA 88 IL 99 NR
6d. DX4: __________________________________________________ 77 NA 88 IL 99 NR
6e. DX5: __________________________________________________ 77 NA 88 IL 99 NR
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Comments:
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C. Maternal Transport by AmbulanceNo information for any item in section |
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1. Transporting Facility |
__ __/__ __ /__ __ __ __
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3. Admit time
_ _ : _ _ |
4. Departure date
__ __/__ __ /__ __ __ __
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5. Departure time
_ _ : _ _ |
6.1. Med record adequate 2. Order medical record 3. Record not available
88 IL 99 NR |
7. Reason for transport |
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Comments:
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D. INJECTIONS/VACCINATIONS NOTED THIS ADMISSION THROUGH 24 HOURS POSTPARTUM No information for any item in section |
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Injection/Vaccination |
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1. Rhogam (other RH(D)) Immunoglobulin 1 Yes 2 No 88 IL 99 NR |
Date (1.dt1, 1.dt2)
1st _ _ / _ _ / _ _ _ _
2nd _ _ / _ _ / _ _ _ _
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Dose (1.ds.1, 1.ds.2)
1st __________
2nd ________
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Manufacturer (1.m.1, 1.m.2)
1st _________
2nd ________
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Product Name (1.p.1, 1.p.2)
1st _________
2nd ________
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Lot # (1.lot.1, 1.lot.2)
_________
__________
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2. Influenza Vaccine 1 Yes 2 No 88 IL 99 NR |
2.dt Date
_ _ / _ _ / _ _ _ _
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2.m Manufacturer
______________
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2.lot Lot #
___________ |
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3. Other 1 Yes 2 No 88 IL 99 NR
3a.sp (specify)
_________________ |
3a.dt Date
_ _ / _ _ / _ _ _ _
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3a.m Manufacturer
______________
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3a.lot Lot #
___________ |
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3b.sp Other (specify)
_________________ |
3b.dt Date
_ _ / _ _ / _ _ _ _
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3b.m Manufacturer
______________
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3b.lot Lot #
___________ |
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3c.sp Other (specify)
_________________ |
3c.dt Date
_ _ / _ _ / _ _ _ _
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3c.m Manufacturer
______________
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3c.lot Lot #
___________ |
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3d.sp Other (specify)
_________________ |
3d.dt Date
_ _ / _ _ / _ _ _ _
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3d.m Manufacturer
______________
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3d.lot Lot #
___________ |
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3e.sp Other (specify)
_________________ |
3e.dt Date
_ _ / _ _ / _ _ _ _
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3e.m Manufacturer
______________
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3e.lot Lot #
___________ |
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3f.sp Other (specify)
_________________ |
3f.dt Date
_ _ / _ _ / _ _ _ _
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3f.m Manufacturer
______________
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3f.lot Lot #
___________ |
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Comments:
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E. Cervical Exam on AdmissionNote: Dilation may be noted as complete, please record as 10cm; Effac may be noted as complete, please record as 100% No information for any item in section |
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1a. Date
__ __/__ __ /__ __ __ __
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1b. Time_ _ : _ _ |
1c. Dil (cm)
88 IL 99 NR |
1d. Effac (%)
88 IL 99 NR |
1e. Station
88 IL 99 NR |
1f.
1. SSE 2. SVE 3. US 88 IL 99 NR |
Comments: |
2a. Date
__ __/__ __ /__ __ __ __
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2b. Time_ _ : _ _ |
2c. Dil (cm)
88 IL 99 NR |
2d. Effac (%)
88 IL 99 NR |
2e. Station
88 IL 99 NR |
2f. 1. SSE 2. SVE 3. US 88 IL 99 NR |
Comments: |
Comments:
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F. INDUCTION OR AUGMENTATION OF LABORNo information for any item in section |
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Method: 1= Prostaglandins for cervical ripening, 2= Artificial rupture of membranes (AROM), 3= Oxytocin/pitocin4= Misoprostol 6= Other (specify), 88=Not Legible 99=Not RecordedReasons for induction/augmentation: 7= Premature ROM 11= Mature amnio1= PIH 4= Chorionamnionitis 8= Prolonged premature ROM 12= Post date 2= Bleeding 5= Low biophysical profile 9= Prolonged ROM (term) 13= Fetal Distress 3= Polyhydramnios 6= Low AFI or oligohydramnios 10= Prolonged labor/uterine dystocia 66= Other (specify) ______ 77=NA 88=Not Legible 99=Not Recorded |
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1a1. Date initiated__ __ / __ __ / __ __ __ __
1b1. Date stopped __ __ / __ __ / __ __ __ __
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1a2.Time Initiated__ __ : __ __
1b2. Time Stopped__ __ : __ __
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1c. Method |
1d. Purpose
1. Induction 2. Augmentation 88 IL 99 NR |
1e. Reason |
1f. Comments |
2a1. Date initiated__ __ / __ __ / __ __ __ __
2b1. Date stopped __ __ / __ __ / __ __ __ __
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2a2.Time Initiated__ __ : __ __
2b2. Time Stopped__ __ : __ __
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2c. Method |
2d. Purpose
1. Induction 2. Augmentation 88 IL 99 NR |
2e. Reason |
2f. Comments |
3a1. Date initiated__ __ / __ __ / __ __ __ __
3b1. Date stopped __ __ / __ __ / __ __ __ __
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3a2.Time Initiated__ __ : __ __
3b2. Time Stopped__ __ : __ __
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3c. Method |
3d. Purpose
1. Induction 2. Augmentation 88 IL 99 NR |
3e. Reason |
3f. Comments |
4a1. Date initiated__ __ / __ __ / __ __ __ __
4b1. Date stopped __ __ / __ __ / __ __ __ __
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4a2.Time Initiated__ __ : __ __
4b2. Time Stopped__ __ : __ __
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4c. Method |
4d. Purpose
1. Induction 2. Augmentation 88 IL 99 NR |
4e. Reason |
4f. Comments |
Comments:
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G. RUPTURE OF MEMBRANESIf “yes” is indicated for medications, please fill out Section N. No information for any item in section |
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__ __/__ __/__ __ __ __ __
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2. Time1. at delivery __ __ : __ __
2. at c-section __ __ : __ __
3. other time __ __ : __ __
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3. Length of time before delivery
1. <1 h 2. 1-12h 3. 12-24h 4. >24 h 88 IL 99 NR |
4. Method
1. Spontaneous 2. Artificial 88 IL 99 NR |
5. Confirming dx(select all that apply)
1. +Pooling 2. +Nitrazine 3. +Ferning 4. +Indigo dye test 5. +History 88 IL 99 NR |
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6. Description of fluid at time of rupture (select all that apply)
1. Clear 2. Yellow 3. Bloody 4. Purulent 5. Foul odor 6. Meconium NOS 7. Thin meconium 8. Thick meconium 9. Moderate meconium 10. Terminal mec 88 IL 99 NR |
7. Note any changes in fluid color/odor
1. No Change Noted 88 IL 99 NR |
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8. Mother’s statement (include where, when, description)
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9. Medication given during ROM1. Yes 2. No 88 IL 99 NR
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Comments:
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H. DELIVERY SUMMARYNo information for any item in section |
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Plurality: 11 = Singleton 20 = Twin NOS 30 =Triplet NOS 40 = Quadruplet NOS
21 =Twin A 31 =Triplet
A 41 = Quadruplet A
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1. Gender
1. Male 2. Female 3. Ambiguous 88 IL 99 NR |
2. Plurality
77 NA 88 IL 99 NR |
3. Zygosity
1. Monozygotic (MZ) 2. Dizygotic (DZ) 77 NA 88 IL 99 NR
3a. Zygosity determined by:
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4. Weight (gm)
88 IL 99 NR |
5. Length (cm)
88 IL 99 NR |
6. Head circumference (cm)
88 IL 99 NR |
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7. Apgar 1’ 5’ 10’ 15’scores
88 IL 99 NR |
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8. Type of delivery
1. NSVD 2. Operative vaginal delivery 3. C-section 4. Breech extraction 88 IL 99 NR
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9. Presentation at delivery
1. Vertex 2. Transverse lie (shoulder presentation) 3. Face/brow 4. Breech 6. Other, (specify):_____ 88 IL 99 NR |
10. Description of delivery 1. Normal 2. Precipitous 3. Prolonged 1st stage 4. Prolonged 2nd stage 88 IL 99 NR
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11. Meconium staining of baby’s (select all that apply)
1. Skin 4. Cord 2. Nails 5. No staining 3. Placenta
88 IL 99 NR |
12. Birth defects (use codes from medical conditions list; write out verbatim any conditions not on list)
12a. Dx1 code________ Text_____________________ 77 NA 88 IL 12b. Dx2 code________ Text_____________________ 77 NA 88 IL 12c. Dx3 code________ Text_____________________ 77 NA 88 IL 12d. Dx4 code________ Text_____________________ 77 NA 88 IL 12e. Dx5 code________ Text_____________________ 77 NA 88 IL 12f. Dx6 code________ Text_____________________ 77 NA 88 IL
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13. Date onset labor
__ __ / __ __ / __ __ __ __ |
14. Time onset __ __ : __ __
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15. If date/time unknown, mother’s statement |
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16. Analgesia in labor 16a. Agent (select all that apply) Nubain Stadol Demerol Fentanyl Other: Specify: _________________ _________________
None
88 IL 99 NR
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16b. Complications:
16b1 Complication 1 __________________________________ 77 NA 88 IL 16b2 Complication 2 __________________________________ 77 NA 88 IL 16b3 Complication 3 __________________________________ 77 NA 88 IL 16b4 Complication 4 __________________________________ 77 NA 88 IL 16b5 Complication 5 __________________________________ 77 NA 88 IL 16b6 Complication 6 __________________________________ 77 NA 88 IL
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16c. Method (when not stated use delivery time)
1. Epidural Epidural start time: __ __ : __ __ Date: ____________ 2. Spinal Spinal/Intrathecal start time: __ __:__ __ Date __________ 3. Local 4. General 5. Perineal 6. Paracervical (saddle block) Spinal/Intrathecal start time: __ __:__ __ Date __________ 7. Pudendal Spinal/Intrathecal start time: __ __:__ __ Date __________ 8. Other (specify):____________
88 IL 99 NR |
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19a. Prep solutions used
1. Yes 2 No 77 NA 88 IL 99 NR
19b. Location: ____________ ________________________ ________________________ ________________________ ________________________ |
20. Preterm delivery
1. Yes 2 No 88 IL 99 NR
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21. Reason for preterm delivery per MD
88 IL 99 NR |
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21. Newborn Screening Accession Number: 88 IL 99 NR
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Comments: |
I. PLACENTA AND CORDNo information for any item in section |
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__ __/__ __/__ __ __ __ __
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2. Time of Placenta Delivery
____:____
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3. 1. Spont. 2. Assisted 3. Manual
88. IL 99. NR
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4. Nuchal cord
4.b. 1. Tight 2. Loose 3. NOS 4. Other: Specify_____________ 5. Nuchal cord not noted 88. IL 99. NR
4a. Times wrapped around neck X_________ 88. IL 99. NR |
5. Cord length1. Long 2. Short 4. Stated length:_______
88. IL 99. NR
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6. Other cord abnormalities (select all that apply)
1. True knot 2. Thin 3. Two vessels 4. Three vessels (normal) 5. Velamentous/marginal insertion 6. Cord prolapse
88. IL 99. NR
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7. Infarcts noted on OB/CNM exam
1. Old 2. New 3. NOS 4. None noted 88. IL 99. NR
7a. Size ________
88. IL 99. NR
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8. Description of placenta on OB/CNM exam (select apply that apply)
Small placenta Fetal papyraceous Abruption _____% Placenta accreta, increta or percreta Placenta previa Complete/total Partial/marginal Low lying Missing lobes Calcification Vascular abnormalities Clot noted other: specify__________________
88. IL 99. NR
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Comments:
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J. PLACENTAL PATHOLOGYNo information for any item in section |
1. Pathology report copied 2. Placenta not sent to pathology (discarded) 3. Status unclear/report not in chart |
Comments:
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K. DELIVERY INTERVENTIONSNo information for any item in section |
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Interventions |
Comments |
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1a. Version
1. yes 2. no
77 NA 88 IL 99 NR |
1b. Date: __ __/__ __/ __ __ __ __
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1c. 1. Successful 2. Failed
88 IL 99 NR |
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2a. Amnio Infusion
1. yes 2. no
77 NA 88 IL 99 NR |
2b. Specify complications:
2b1 Complication 1 ___________________________________ 77 NA 88 IL 2b2 Complication 2 ___________________________________ 77 NA 88 IL 2b3 Complication 3 ___________________________________ 77 NA 88 IL 2b4 Complication 4 ___________________________________ 77 NA 88 IL 2b5 Complication 5 ___________________________________ 77 NA 88 IL 2b6 Complication 6 ___________________________________ 77 NA 88 IL |
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3a. Vacuum
1. yes 2. no
77 NA 88 IL 99 NR |
3b.
1. Successful 2. Failed
88 IL 99 NR |
3c
Total time on ________min
88 IL 99 NR |
3d.
Number of Pulls _________
88 IL 99 NR
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4a.
Forceps
1. yes 2. no
77 NA 88 IL 99 NR |
4b.
1. Successful 2. Failed
88 IL 99 NR
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4c.
Total time on ________min
88 IL 99 NR
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4e.
1. Outlet 2. Low 3. Mid 4. Rotation
88 IL 99 NR |
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4d. Number of Pulls _________
88 IL 99 NR
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5a.
Cesarean Section
1. yes 2. no
77 NA 88 IL 99 NR
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5b.
1. Elective 2. Unscheduled 3. Emergency, 5b1. Specify: _____________________________________________________
88 IL 99 NR
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Comments:
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Section K Part 2: Complications of Labor and DeliveryCheck all that apply
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No Complications Noted (Skip to section L)
Active Phase Arrest (APA) Arrest of descent Cephalopelvic Disproportion (CPD) Cholestasis of pregnancy or intrahepatic cholestasis Deep Transverse Arrest Failed Trial of Labor Failure to progress (FTP) Failure to descend
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Fetal distress or intolerance of labor (FIOL) Herpes (genital), Active only Intra-uterine growth retardation (IUGR) Low BPP or non-reassuring fetal testing Macrosomia Maternal death Oligohydramnios or Low AFI Persistent OP
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Polyhydramnios Post-dates Postpartum hemorrhage Hemabate given Methergine given Uterine Artery Embolization Prolonged latent stage Retained placenta Seizure, infant Shoulder dystocia Slow Slope Active Phase Uterine atony Uterine rupture Vasa previa VBAC Other (specify):_________________
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L (part 1). MATERNAL INFECTIONS NOTED THIS ADMISSION THROUGH 24 HOURS POSTPARTUM Extra sheet provided in Appendix A if needed Dx: Use codes from infection list (Appendix D) If cultures were performed, note in section M. If “yes” is indicated for medications, please fill out Section N. No information for any item in section |
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1a Dx |
1b.1 Date diagnosed
_ _ / _ _ / _ _ _ _ OR 1b.ga GA _____ wks
OR 1b.tri Trimester _____
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1c Duration
______ days
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1d Certainty of Dx
1. Lab/Test 2. Clinical 3. Suspect 9. unknown
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1e.1 Highest Temp
_______
1e.2 Unit 1. oC 2 oF 88 IL 99 NR |
1f.1 Lowest Temp
_______
1f.2 Unit 1. oC 2 oF 88 IL 99 NR |
1g Cultures/Rapid Screen done?
1 Yes 2 No 88 IL 99 NR |
1h Meds given?
1 Yes 2 No 88 IL 99 NR |
2a Dx |
2b.1 Date diagnosed
_ _ / _ _ / _ _ _ _ OR 2b.ga GA _____ wks
OR 2b.tri Trimester _____
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2c Duration
______ days
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2d Certainty of Dx
1. Lab/Test 2. Clinical 3. Suspect 9. unknown |
2e.1 Highest Temp
_______
2e.2 Unit 1. oC 2 oF 88 IL 99 NR |
2f.1 Lowest Temp
_______
2f.2 Unit 1. oC 2 oF 88 IL 99 NR |
2g Cultures/Rapid Screen done?
1 Yes 2 No 88 IL 99 NR |
2h Meds given?
1 Yes 2 No 88 IL 99 NR |
3a Dx |
3b.1 Date diagnosed
_ _ / _ _ / _ _ _ _ OR 3b.ga GA _____ wks
OR 3b.tri Trimester _____
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3c Duration
______ days
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3d Certainty of Dx
1. Lab/Test 2. Clinical 3. Suspect 9. unknown |
3e.1 Highest Temp
_______
3e.2 Unit 1. oC 2 oF 88 IL 99 NR |
3f.1 Lowest Temp
_______
3f.2 Unit 1. oC 2 oF 88 IL 99 NR |
3g Cultures/Rapid Screen done?
1 Yes 2 No 88 IL 99 NR |
3h Meds given?
1 Yes 2 No 88 IL 99 NR |
4a Dx |
4b.1 Date diagnosed
_ _ / _ _ / _ _ _ _ OR 4b.ga GA _____ wks
OR 4b.tri Trimester _____
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4c Duration
______ days
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4d Certainty of Dx
1. Lab/Test 2. Clinical 3. Suspect 9. unknown |
4e.1 Highest Temp
_______
4e.2 Unit 1. oC 2 oF 88 IL 99 NR |
4f.1 Lowest Temp
_______
4f.2 Unit 1. oC 2 oF 88 IL 99 NR |
4g Cultures/Rapid Screen done?
1 Yes 2 No 88 IL 99 NR |
4h Meds given?
1 Yes 2 No 88 IL 99 NR |
Comments: Specify any other DX (code=600) as 1a.sp, 2a.sp, 3a.sp, 4a.sp Also list other comments. |
L (PART 2) SIGNS AND SYMPTOMS (S/S) FOR DELIVERY TO 24 HOURS POSTPARTUM No information for any item in section |
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S/S |
Date first noted |
Time |
1. Uterine Tenderness
Yes No Suspect IL NR |
1a.
__ __ / __ __ / __ __ __ __ |
1b.
__ __ : __ __ |
2. Foul vaginal discharge note (odor)
Yes No Suspect IL NR |
2a.
__ __ / __ __ / __ __ __ __ |
2b.
__ __ : __ __ |
3. Purulent amniotic fluid (color)
Yes No Suspect IL NR |
3a.
__ __ / __ __ / __ __ __ __ |
3b.
__ __ : __ __ |
4. WBC count > 15,000/mL
Yes No Suspect IL NR |
4a.
__ __ / __ __ / __ __ __ __ |
4b.
__ __ : __ __ |
5. Persistent mat’t tachycardia (>100 bpm)
Yes No Suspect IL NR |
5a.
__ __ / __ __ / __ __ __ __ |
5b
__ __ : __ __ |
6. Persistent fetal tachycardia (>160 bpm)
Yes No Suspect IL NR |
6a.
__ __ / __ __ / __ __ __ __ |
6b.
__ __ : __ __ |
7. Fetal bradycardia
Yes No Suspect IL NR |
7a.
__ __ / __ __ / __ __ __ __ |
7b.
__ __ : __ __ |
8. Periodic Changes
Yes No Suspect IL NR |
8a.
__ __ / __ __ / __ __ __ __ |
8b.
__ __ : __ __ |
9. Other, 9a. Specify _______________________
Yes No Suspect IL NR |
__ __ / __ __ / __ __ __ __ |
__ __ : __ __ |
Comments:
|
L (part 3). Fever >37.7 oC or 100 oF ON ADMISSION TO 24 HOURS POSTPARTUM No information for any item in section |
|||
|
5 highest fevers |
Date |
Time |
1. |
1a.1 Highest Temp
_______ 1a.2 Unit 1. oC 2 oF 88 IL 99 NR |
1b
_ _ / _ _ / _ _ _ _
|
1c (military time)
___ ___ : ___ ___
|
2. |
2a.1 Highest Temp
_______ 2a.2 Unit 1. oC 2 oF 88 IL 99 NR |
2b
_ _ / _ _ / _ _ _ _
|
2c (military time)
___ ___ : ___ ___
|
3. |
3a.1 Highest Temp
_______ 3a.2 Unit 1. oC 2 oF 88 IL 99 NR |
3b
_ _ / _ _ / _ _ _ _
|
3c (military time)
___ ___ : ___ ___
|
4. |
4a.1 Highest Temp
_______ 4a.2 Unit 1. oC 2 oF 88 IL 99 NR |
4b
_ _ / _ _ / _ _ _ _
|
4c (military time)
___ ___ : ___ ___
|
5. |
5a.1 Highest Temp
_______ 5a.2 Unit 1. oC 2 oF 88 IL 99 NR |
5b
_ _ / _ _ / _ _ _ _
|
5c (military time)
___ ___ : ___ ___
|
Comments:
|
M. CULTURES/RAPID STREP SCREENS OBTAINED THIS ADMISSION (RECORD ALL CULTURES /STREP SCREENS OBTAINED) Extra sheet provided in Appendix A if needed Indicate the number of the event from section L or ‘0’ If culture does not correspond to an event in section L. No information for any item in section Test/procedure for one or more items in section indicated but no information on dates, results, etc. |
||||
Source: 1 = amniotic fluid; 2 = placenta; 3 = cervix; 4 = vagina; 5 = urine; 6 = blood; 7 = sputum; 8=throat; 9 = stool; 10=wound; 11= other (specify); 88 = Illegible 99=Not recorded |
||||
1a – 20a
REF |
1b – 20b
Date Cultured |
1c–20c 1c.sp-20c.sp (specify) Source |
1d – 20d (1d.6.sp – 20d.6.sp and 1d.9.sp – 20d.9.sp for specify fields)
Results |
1e – 20e
Description (organisms, etc.) |
|
_ _ / _ _ / _ _ _ _
|
|
1. no growth 2. Normal flora 3. light growth 4. mod-heavy growth 5. growth noted, not specified 6. urine culture colony count (specify)_________________________ 7. rapid strep screen pos 8. rapid strep screen neg 9. other (specify)_________________________ 88. IL 99. NR |
|
|
_ _ / _ _ / _ _ _ _
|
|
1. no growth 2. Normal flora 3. light growth 4. mod-heavy growth 5. growth noted, not specified 6. urine culture colony count (specify)_________________________ 7. rapid strep screen pos 8. rapid strep screen neg 9. other (specify)_________________________ 88. IL 99. NR |
|
|
_ _ / _ _ / _ _ _ _
|
|
1. no growth 2. Normal flora 3. light growth 4. mod-heavy growth 5. growth noted, not specified 6. urine culture colony count (specify)_________________________ 7. rapid strep screen pos 8. rapid strep screen neg 9. other (specify)_________________________ 88. IL 99. NR |
|
|
_ _ / _ _ / _ _ _ _
|
|
1. no growth 2. Normal flora 3. light growth 4. mod-heavy growth 5. growth noted, not specified 6. urine culture colony count (specify)_________________________ 7. rapid strep screen pos 8. rapid strep screen neg 9. other (specify)_________________________ 88. IL 99. NR |
|
|
_ _ / _ _ / _ _ _ _
|
|
1. no growth 2. Normal flora 3. light growth 4. mod-heavy growth 5. growth noted, not specified 6. urine culture colony count (specify)_________________________ 7. rapid strep screen pos 8. rapid strep screen neg 9. other (specify)_________________________ 88. IL 99. NR |
|
M.CULTURES/RAPID STREP SCREENS (continued) |
||||
Source: 1 = amniotic fluid; 2 = placenta; 3 = cervix; 4 = vagina; 5 = urine; 6 = blood; 7 = sputum; 8=throat; 9 = stool; 10=wound; 11= other (specify); 88 = Illegible 99=Not recorded |
||||
1a – 20a
REF |
1b – 20b
Date Cultured |
1c–20c 1c.sp-20c.sp (specify) Source |
1d – 20d (1d.6.sp – 20d.6.sp and 1d.9.sp – 20d.9.sp for specify fields)
Results |
1e – 20e
Description (organisms, etc.) |
|
_ _ / _ _ / _ _ _ _
|
|
1. no growth 2. Normal flora 3. light growth 4. mod-heavy growth 5. growth noted, not specified 6. urine culture colony count (specify)_________________________ 7. rapid strep screen pos 8. rapid strep screen neg 9. other (specify)_________________________ 88. IL 99. NR |
|
|
_ _ / _ _ / _ _ _ _
|
|
1. no growth 2. Normal flora 3. light growth 4. mod-heavy growth 5. growth noted, not specified 6. urine culture colony count (specify)_________________________ 7. rapid strep screen pos 8. rapid strep screen neg 9. other (specify)_________________________ 88. IL 99. NR |
|
|
_ _ / _ _ / _ _ _ _
|
|
1. no growth 2. Normal flora 3. light growth 4. mod-heavy growth 5. growth noted, not specified 6. urine culture colony count (specify)_________________________ 7. rapid strep screen pos 8. rapid strep screen neg 9. other (specify)_________________________ 88. IL 99. NR |
|
|
_ _ / _ _ / _ _ _ _
|
|
1. no growth 2. Normal flora 3. light growth 4. mod-heavy growth 5. growth noted, not specified 6. urine culture colony count (specify)_________________________ 7. rapid strep screen pos 8. rapid strep screen neg 9. other (specify)_________________________ 88. IL 99. NR |
|
|
_ _ / _ _ / _ _ _ _
|
|
1. no growth 2. Normal flora 3. light growth 4. mod-heavy growth 5. growth noted, not specified 6. urine culture colony count (specify)_________________________ 7. rapid strep screen pos 8. rapid strep screen neg 9. other (specify)_________________________ 88. IL 99. NR |
|
Comments:
|
N. ALL MEDICATIONS (INCLUDING ALL ANTI-INFECTIVES, STEROIDS, HORMONES, AND OTHER MEDICATIONS) TAKEN THIS ADMISSION THROUGH 24 HOURS POSTPARTUM
Extra sheet provided in Appendix A if needed No information for any item in section |
|||||||
Refer: Indicate the number of the event from the corresponding section. If the medication does not correspond to a section above, enter ‘0’. Drug Codes: 9 = Steroids (lung maturity); 10 = antidiabetes; 11 = steroids (other); 12 = hormones; 13 = thyroid; 14 = antibiotics; 15 = antifungals; 16 = antivirals; 17 = anesthetics (not labor and delivery); 18 = anticonvulsants; 19 = analgesics/hypnotics/sedatives/antipsychotics; 20 = antihypertensives/diuretics; 21 = cardiovascular; 22 = narcotic agents; 23 = ergotrate; 24 = antidepressants; 25 = prenatal vitamins; 26 = asthma; 27 = preterm labor prevention; 88 = other (specify); 99 = unknown Exclusions: laxatives, enemas, disinfectants, topical agents, cough medicine, non-prenatal vitamins, antacids, stool softeners, benadryl, Tylenol, methergine, labor and delivery anesthetics (recorded in Section F) |
|||||||
1a - 30a Refer |
1b - 30b Code |
1c - 30c
Drug Name |
1d - 30d
Start Date |
1e - 30e 1e.ep – 30e.ep Stop Date |
1f - 30f 1f.sp – 30f.sp Dose |
1g - 30g 1g.sp – 30g.sp Unit |
1h - 30h 1h.sp – 30h.sp Freq |
|
|
|
_ _ / _ _ / _ _ _ _
|
_ _ / _ _ / _ _ _ _
OR
Entire pregnancy or ongoing |
8. variable |
1. gm 2. mg 3. mcg 4. mU 5. cc/ml 8. other_____
88. Illegible 99. NR |
1. QD 2. BID 3. TID 4. QID 5. PRN 6. Every ___ hrs 7. Per week 8. Total dose
88. Illegible 99. NR |
|
|
|
_ _ / _ _ / _ _ _ _
|
_ _ / _ _ / _ _ _ _
OR
Entire pregnancy or ongoing |
8. variable |
1. gm 2. mg 3. mcg 4. mU 5. cc/ml 8. other_____
88. Illegible 99. NR |
1. QD 2. BID 3. TID 4. QID 5. PRN 6. Every ___ hrs 7. Per week 8. Total dose
88. Illegible 99. NR |
|
|
|
_ _ / _ _ / _ _ _ _
|
_ _ / _ _ / _ _ _ _
OR
Entire pregnancy or ongoing |
8. variable |
1. gm 2. mg 3. mcg 4. mU 5. cc/ml 8. other_____
88. Illegible 99. NR |
1. QD 2. BID 3. TID 4. QID 5. PRN 6. Every ___ hrs 7. Per week 8. Total dose
88. Illegible 99. NR |
|
|
|
_ _ / _ _ / _ _ _ _
|
_ _ / _ _ / _ _ _ _
OR
Entire pregnancy or ongoing |
8. variable |
1. gm 2. mg 3. mcg 4. mU 5. cc/ml 8. other_____
88. Illegible 99. NR |
1. QD 2. BID 3. TID 4. QID 5. PRN 6. Every ___ hrs 7. Per week 8. Total dose
88. Illegible 99. NR |
N. ALL MEDICATIONS (continued) |
|||||||
Refer: Indicate the number of the event from the corresponding section. If the medication does not correspond to a section above, enter ‘0’. Drug Codes: 9 = Steroids (lung maturity); 10 = antidiabetes; 11 = steroids (other); 12 = hormones; 13 = thyroid; 14 = antibiotics; 15 = antifungals; 16 = antivirals; 17 = anesthetics (not labor and delivery); 18 = anticonvulsants; 19 = analgesics/hypnotics/sedatives/antipsychotics; 20 = antihypertensives/diuretics; 21 = cardiovascular; 22 = narcotic agents; 23 = ergotrate; 24 = antidepressants; 25 = prenatal vitamins; 26 = asthma; 27 = preterm labor prevention; 88 = other (specify); 99 = unknown Exclusions: laxatives, enemas, disinfectants, topical agents, cough medicine, non-prenatal vitamins, antacids, stool softeners, benadryl, Tylenol, methergine, labor and delivery anesthetics (recorded in Section F) |
|||||||
1a - 30a Refer |
1b - 30b Code |
1c - 30c
Drug Name |
1d - 30d
Start Date |
1e - 30e 1e.ep – 30e.ep Stop Date |
1f - 30f 1f.sp – 30f.sp Dose |
1g - 30g 1g.sp – 30g.sp Unit |
1h - 30h 1h.sp – 30h.sp Freq |
|
|
|
_ _ / _ _ / _ _ _ _
|
_ _ / _ _ / _ _ _ _
OR
Entire pregnancy or ongoing |
8. variable |
1. gm 2. mg 3. mcg 4. mU 5. cc/ml 8. other_____
88. Illegible 99. NR |
1. QD 2. BID 3. TID 4. QID 5. PRN 6. Every ___ hrs 7. Per week 8. Total dose
88. Illegible 99. NR |
|
|
|
_ _ / _ _ / _ _ _ _
|
_ _ / _ _ / _ _ _ _
OR
Entire pregnancy or ongoing |
8. variable |
1. gm 2. mg 3. mcg 4. mU 5. cc/ml 8. other_____
88. Illegible 99. NR |
1. QD 2. BID 3. TID 4. QID 5. PRN 6. Every ___ hrs 7. Per week 8. Total dose
88. Illegible 99. NR |
|
|
|
_ _ / _ _ / _ _ _ _
|
_ _ / _ _ / _ _ _ _
OR
Entire pregnancy or ongoing |
8. variable |
1. gm 2. mg 3. mcg 4. mU 5. cc/ml 8. other_____
88. Illegible 99. NR |
1. QD 2. BID 3. TID 4. QID 5. PRN 6. Every ___ hrs 7. Per week 8. Total dose
88. Illegible 99. NR |
|
|
|
_ _ / _ _ / _ _ _ _
|
_ _ / _ _ / _ _ _ _
OR
Entire pregnancy or ongoing |
8. variable |
1. gm 2. mg 3. mcg 4. mU 5. cc/ml 8. other_____
88. Illegible 99. NR |
1. QD 2. BID 3. TID 4. QID 5. PRN 6. Every ___ hrs 7. Per week 8. Total dose
88. Illegible 99. NR |
N. ALL MEDICATIONS (continued) |
|||||||
Refer: Indicate the number of the event from the corresponding section. If the medication does not correspond to a section above, enter ‘0’. Drug Codes: 9 = Steroids (lung maturity); 10 = antidiabetes; 11 = steroids (other); 12 = hormones; 13 = thyroid; 14 = antibiotics; 15 = antifungals; 16 = antivirals; 17 = anesthetics (not labor and delivery); 18 = anticonvulsants; 19 = analgesics/hypnotics/sedatives/antipsychotics; 20 = antihypertensives/diuretics; 21 = cardiovascular; 22 = narcotic agents; 23 = ergotrate; 24 = antidepressants; 25 = prenatal vitamins; 26 = asthma; 27 = preterm labor prevention; 88 = other (specify); 99 = unknown Exclusions: laxatives, enemas, disinfectants, topical agents, cough medicine, non-prenatal vitamins, antacids, stool softeners, benadryl, Tylenol, methergine, labor and delivery anesthetics (recorded in Section F) |
|||||||
1a - 30a Refer |
1b - 30b Code |
1c - 30c
Drug Name |
1d - 30d
Start Date |
1e - 30e 1e.ep – 30e.ep Stop Date |
1f - 30f 1f.sp – 30f.sp Dose |
1g - 30g 1g.sp – 30g.sp Unit |
1h - 30h 1h.sp – 30h.sp Freq |
|
|
|
_ _ / _ _ / _ _ _ _
|
_ _ / _ _ / _ _ _ _
OR
Entire pregnancy or ongoing |
8. variable |
1. gm 2. mg 3. mcg 4. mU 5. cc/ml 8. other_____
88. Illegible 99. NR |
1. QD 2. BID 3. TID 4. QID 5. PRN 6. Every ___ hrs 7. Per week 8. Total dose
88. Illegible 99. NR |
|
|
|
_ _ / _ _ / _ _ _ _
|
_ _ / _ _ / _ _ _ _
OR
Entire pregnancy or ongoing |
8. variable |
1. gm 2. mg 3. mcg 4. mU 5. cc/ml 8. other_____
88. Illegible 99. NR |
1. QD 2. BID 3. TID 4. QID 5. PRN 6. Every ___ hrs 7. Per week 8. Total dose
88. Illegible 99. NR |
|
|
|
_ _ / _ _ / _ _ _ _
|
_ _ / _ _ / _ _ _ _
OR
Entire pregnancy or ongoing |
8. variable |
1. gm 2. mg 3. mcg 4. mU 5. cc/ml 8. other_____
88. Illegible 99. NR |
1. QD 2. BID 3. TID 4. QID 5. PRN 6. Every ___ hrs 7. Per week 8. Total dose
88. Illegible 99. NR |
|
|
|
_ _ / _ _ / _ _ _ _
|
_ _ / _ _ / _ _ _ _
OR
Entire pregnancy or ongoing |
8. variable |
1. gm 2. mg 3. mcg 4. mU 5. cc/ml 8. other_____
88. Illegible 99. NR |
1. QD 2. BID 3. TID 4. QID 5. PRN 6. Every ___ hrs 7. Per week 8. Total dose
88. Illegible 99. NR |
File Type | application/msword |
File Title | IDENTIFYING INFORMATION |
Author | Roxana Odouli |
Last Modified By | Lisa Young |
File Modified | 2009-03-27 |
File Created | 2009-03-27 |