Appendix_S

Appendix_S.3 Labor and Delivery MR Form Final.doc

The Study to Explore Early Development (SEED)

Appendix_S

OMB: 0920-0741

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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

A.1. Name of Provider/Hospital

A.2. Street Address


A.3. City

A.4. State

A.5. Zip Code

ABSTRACTION LOG

A.6. Date __ __/__ __/__ __ __ __

A.7. Date __ __/__ __/__ __ __ __

A.8. Date __ __/__ __/__ __ __ __

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 __ __: __ __

A.9. Date __ __/__ __/__ __ __ __

A.10. Date __ __/__ __/__ __ __ __

A.11. Date __ __/__ __/__ __ __ __

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 __ __: __ __




B.1. Name of Provider/Hospital

B.2. Street Address


B.3. City

B.4. State

B.5. Zip Code

ABSTRACTION LOG

B.6. Date __ __/__ __/__ __ __ __

B.7. Date __ __/__ __/__ __ __ __

B.8. Date __ __/__ __/__ __ __ __

B.6.1 to B.6.8 Time (*use military time)


Start __ __ : __ __ Stop __ __: __ __

Start __ __ : __ __ Stop __ __: __ __

Start __ __ : __ __ Stop __ __: __ __


B.71 to B.7.8 Time (*use military time)


Start __ __ : __ __ Stop __ __: __ __

Start __ __ : __ __ Stop __ __: __ __

Start __ __ : __ __ Stop __ __: __ __




B.8.1 to B.8.8 Time (*use military time)


Start __ __ : __ __ Stop __ __: __ __

Start __ __ : __ __ Stop __ __: __ __

Start __ __ : __ __ Stop __ __: __ __


B.9. Date __ __/__ __/__ __ __ __

B.10. Date __ __/__ __/__ __ __ __

B.11. Date __ __/__ __/__ __ __ __

B.9.1 to B.9.8 Time (*use military time)


Start __ __ : __ __ Stop __ __: __ __

Start __ __ : __ __ Stop __ __: __ __

Start __ __ : __ __ Stop __ __: __ __




B.10.1 to B.10.8 Time (*use military time)


Start __ __ : __ __ Stop __ __: __ __

Start __ __ : __ __ Stop __ __: __ __

Start __ __ : __ __ Stop __ __: __ __





B.11.1 to B.11.8 Time (*use military time)


Start __ __ : __ __ Stop __ __: __ __

Start __ __ : __ __ Stop __ __: __ __

Start __ __ : __ __ Stop __ __: __ __






A. IDENTIFYING INFORMATION

No information for any item in section

  1. Mother’s name (Last, First, Middle)



2. Study ID#

3. Maiden Name

4. AKA



5. Mother’s DOB

6. Street Address (from L&D chart)




7. City

8. State

9. Zip Code


_ _ _ _ _-_ _ _ _



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


11. Delivery Hospital Name


12. Hospital Street Address


13. City

14. State

15. Zip Code


_ _ _ _ _-_ _ _ _



Comments:























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

  1. NA

  1. 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

  1. Admit date


__ __/__ __ /__ __ __ __


2. Admit time


_ _ : _ _

3. Delivery date


__ __/__ __ /__ __ __ __


4. Delivery time


_ _ : _ _


5. Discharge date


__ __/__ __ /__ __ __ __


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


Comments:











C. Maternal Transport by Ambulance

No information for any item in section

1. Transporting Facility

  1. Admit date



__ __/__ __ /__ __ __ __


3. Admit time


_ _ : _ _

4. Departure date



__ __/__ __ /__ __ __ __


5. Departure time


_ _ : _ _

6.

1. Med record adequate

2. Order medical record

3. Record not available


88 IL 99 NR

7. Reason for transport

Comments:





















D. INJECTIONS/VACCINATIONS NOTED THIS ADMISSION THROUGH 24 HOURS POSTPARTUM

No information for any item in section

Injection/Vaccination






1. Rhogam (other RH(D)) Immunoglobulin

1 Yes

2 No

88 IL

99 NR

Date

(1.dt1, 1.dt2)


1st _ _ / _ _ / _ _ _ _


2nd _ _ / _ _ / _ _ _ _


Dose

(1.ds.1, 1.ds.2)


1st __________


2nd ________


Manufacturer

(1.m.1, 1.m.2)


1st _________


2nd ________


Product Name

(1.p.1, 1.p.2)


1st _________


2nd ________


Lot #

(1.lot.1, 1.lot.2)


_________


__________


2. Influenza Vaccine

1 Yes

2 No

88 IL

99 NR

2.dt

Date


_ _ / _ _ / _ _ _ _


2.m

Manufacturer


______________


2.lot

Lot #


___________

3. Other

1 Yes

2 No

88 IL

99 NR


3a.sp

(specify)


_________________

3a.dt

Date


_ _ / _ _ / _ _ _ _


3a.m

Manufacturer


______________


3a.lot

Lot #


___________

3b.sp

Other (specify)


_________________

3b.dt

Date


_ _ / _ _ / _ _ _ _


3b.m

Manufacturer


______________


3b.lot

Lot #


___________

3c.sp

Other (specify)


_________________

3c.dt

Date


_ _ / _ _ / _ _ _ _


3c.m

Manufacturer


______________


3c.lot

Lot #


___________

3d.sp

Other (specify)


_________________

3d.dt

Date


_ _ / _ _ / _ _ _ _


3d.m

Manufacturer


______________


3d.lot

Lot #


___________

3e.sp

Other (specify)


_________________

3e.dt

Date


_ _ / _ _ / _ _ _ _


3e.m

Manufacturer


______________


3e.lot

Lot #


___________

3f.sp

Other (specify)


_________________

3f.dt

Date


_ _ / _ _ / _ _ _ _


3f.m

Manufacturer


______________


3f.lot

Lot #


___________

Comments:










E. Cervical Exam on Admission

Note: 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

1a. Date


__ __/__ __ /__ __ __ __


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


__ __/__ __ /__ __ __ __





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:





F. INDUCTION OR AUGMENTATION OF LABOR

No information for any item in section

Method: 1= Prostaglandins for cervical ripening, 2= Artificial rupture of membranes (AROM), 3= Oxytocin/pitocin

4= Misoprostol 6= Other (specify), 88=Not Legible 99=Not Recorded

Reasons for induction/augmentation: 7= Premature ROM 11= Mature amnio

1= 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

1a1. Date initiated

__ __ / __ __ / __ __ __ __


1b1. Date stopped

__ __ / __ __ / __ __ __ __


1a2.Time Initiated

__ __ : __ __


1b2. Time Stopped

__ __ : __ __


1c. Method

1d. Purpose


1. Induction

2. Augmentation

88 IL

99 NR

1e. Reason

1f. Comments

2a1. Date initiated

__ __ / __ __ / __ __ __ __


2b1. Date stopped

__ __ / __ __ / __ __ __ __


2a2.Time Initiated

__ __ : __ __


2b2. Time Stopped

__ __ : __ __


2c. Method

2d. Purpose


1. Induction

2. Augmentation

88 IL

99 NR

2e. Reason

2f. Comments

3a1. Date initiated

__ __ / __ __ / __ __ __ __


3b1. Date stopped

__ __ / __ __ / __ __ __ __


3a2.Time Initiated

__ __ : __ __


3b2. Time Stopped

__ __ : __ __


3c. Method

3d. Purpose


1. Induction

2. Augmentation

88 IL

99 NR

3e. Reason

3f. Comments

4a1. Date initiated

__ __ / __ __ / __ __ __ __


4b1. Date stopped

__ __ / __ __ / __ __ __ __



4a2.Time Initiated

__ __ : __ __


4b2. Time Stopped

__ __ : __ __


4c. Method

4d. Purpose


1. Induction

2. Augmentation

88 IL

99 NR

4e. Reason

4f. Comments

Comments:









G. RUPTURE OF MEMBRANES

If “yes” is indicated for medications, please fill out Section N.

No information for any item in section

  1. Date


__ __/__ __/__ __ __ __ __



2. Time

1. at delivery

__ __ : __ __


2. at c-section

__ __ : __ __


3. other time

__ __ : __ __


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

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

8. Mother’s statement (include where, when, description)



9. Medication given during ROM

1. Yes

2. No

88 IL

99 NR



Comments:




H. DELIVERY SUMMARY

No information for any item in section

Plurality: 11 = Singleton 20 = Twin NOS 30 =Triplet NOS 40 = Quadruplet NOS

21 =Twin A 31 =Triplet A 41 = Quadruplet A
22
= Twin B 32 = Triplet B 42 = Quadruplet B
33 =Triplet C 43 = Quadruplet C
44
= Quadruplet D

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:



4. Weight (gm)





88 IL 99 NR

5. Length (cm)





88 IL

99 NR

6. Head circumference (cm)






88 IL 99 NR

7. Apgar 1’ 5’ 10’ 15’

scores


88 IL 99 NR

8. Type of delivery


1. NSVD

2. Operative vaginal delivery

3. C-section

4. Breech extraction

88 IL

99 NR


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


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


13. Date onset labor


__ __ / __ __ / __ __ __ __

14. Time onset

__ __ : __ __


15. If date/time unknown, mother’s statement

16. Analgesia in labor

16a. Agent (select all that apply)

Nubain

Stadol

Demerol

Fentanyl

Other: Specify:

_________________

_________________


None


88 IL 99 NR




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















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

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



21. Reason for preterm delivery per MD





88 IL 99 NR

21. Newborn Screening Accession Number: 88 IL 99 NR


Comments:


















I. PLACENTA AND CORD

No information for any item in section

  1. Date of Placenta Delivery


__ __/__ __/__ __ __ __ __





2. Time of Placenta Delivery


____:____



3. 1. Spont.

2. Assisted

3. Manual

88. IL

99. NR


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 length

1. Long

2. Short

4. Stated length:_______


88. IL

99. NR


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


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


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


Comments:






J. PLACENTAL PATHOLOGY

No 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:










K. DELIVERY INTERVENTIONS

No information for any item in section


Interventions
Comments


1a.

Version


1. yes

2. no


77 NA

88 IL

99 NR

1b.

Date: __ __/__ __/ __ __ __ __

1c.

1. Successful 2. Failed


88 IL 99 NR


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


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



4a.


Forceps


1. yes

2. no


77 NA

88 IL

99 NR

4b.


1. Successful

2. Failed



88 IL

99 NR


4c.


Total time on ________min


88 IL 99 NR


4e.


1. Outlet

2. Low

3. Mid

4. Rotation


88 IL 99 NR

4d.

Number of Pulls _________


88 IL 99 NR



5a.


Cesarean Section


1. yes

2. no


77 NA

88 IL

99 NR


5b.


1. Elective

2. Unscheduled

3. Emergency, 5b1. Specify: _____________________________________________________


88 IL 99 NR


Comments:





Section K Part 2: Complications of Labor and Delivery

Check all that apply



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



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



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):_________________




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

1a

Dx

1b.1

Date diagnosed


_ _ / _ _ / _ _ _ _

OR

1b.ga

GA _____ wks


OR

1b.tri

Trimester _____


1c

Duration


______ days


1d

Certainty of Dx


1. Lab/Test

2. Clinical

3. Suspect

9. unknown



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 _____


2c

Duration


______ days


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 _____


3c

Duration


______ days


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 _____


4c

Duration


______ days


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

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 Typeapplication/msword
File TitleIDENTIFYING INFORMATION
AuthorRoxana Odouli
Last Modified ByLisa Young
File Modified2009-03-27
File Created2009-03-27

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