Appendix S.4 Neonatal MR Form

Study ID Number

CADDRE

Neonatal Medical Record

ABSTRACTION FORM

(11/15/05)

A. identifying Information
Name (Last, First, Middle, Suffix) (Name of identified child for study)
AKA		5. Date of birth _ _/_ _/_ _ _ _		6. Time of Birth _ _ : _ _
7. Mother’s Name (Last, First, Middle)		8. Mother’s Maiden Name		9. Mother’s SSN
10. Street Address		11. City		12. State		13. Zip Code
14. Birth Hospital Name		15. Baby’s Medical Record #		16. Mother’s Medical Record #
17. Hospital Address		18. City		19. State	20. Zip code
21. Father’s Name (Last, First, Middle)
22. Time @ 4-hour Age Date _ _/_ _/_ _ _ _ Time _ _:_ _	23. Time @ 12-hour Age Date _ ­_/_ _/_ _ _ _ Time _ _ : _ _		Time @ 24-hour Age Date _ _/_ _/_ _ _ _ Time _ _:_ _	25. Time @ 48-hour Age Date _ _/_ _/_ _ _ _ Time _ _ : _ _
Date Abstracted __ __/__ __/__ __ __ __			26. Abstractor
Start Time __ __ : __ __			Stop Time __ __ : __ __
Start Time __ __ : __ __			Stop Time __ __ : __ __
Start Time __ __ : __ __			Stop Time __ __ : __ __
Start Time __ __ : __ __			Stop Time __ __ : __ __
Comments

A.Infant transport  No Info
FIRST INFANT TRANSPORT
1. Name of Receiving Hospital	2. Baby’s MR# (receiving hospital)	3. Date Arrived _ _/_ _/_ _	4. Date Departed _ _/_ _/_ _	5. Reason for Transport
				6. Transport Service
SECOND INFANT TRANSPORT
1. Name of Receiving Hospital	2. Baby’s MR# (receiving hospital)	3. Date Arrived _ _/_ _/_ _	4. Date Departed _ _/_ _/_ _	5. Reason for Transport
				6. Transport Service
THIRD INFANT TRANSPORT
1. Name of Receiving Hospital	2. Baby’s MR# (receiving hospital)	3. Date Arrived _ _/_ _/_ _	4. Date Departed _ _/_ _/_ _	5. Reason for Transport
				6. Transport Service
7. Comments:

B.temperatures  No Info
1. Initial temp (nursery admit) ______.______ 1 oF 2 oC 9  Unknown Mode: 1 Skin, 2  Axillary, 3  Rectal, 9  Unknown		2. Initial temp date __ __/__ __/__ __ __ __	3. Initial temp time __ __ : __ __ 9  Unknown
4. Lowest temp in first 48 hrs ______.______ 1 oF 2 oC 9  Unknown Mode: 1 Skin, 2  Axillary, 3  Rectal, 9  Unknown	5. Highest temp in first 48 hrs ______.______ 1 oF 2 oC 9  Unknown Mode: 1 Skin, 2  Axillary, 3  Rectal, 9  Unknown
6. Comments

d. First BABY gases (within first 2 hours after birth)  No Info
	Time drawn	pH	BE/BD
1.	:
2.	:
3.	:
4.	:
Comments:

E. Respiratory support  No Info
Mode of respiratory support: 1 = IMV, 2 = (N)CPAP, 3 = Oxy hood, 4 = NC, 5 = HFV, 6 = Nitric Oxide, 8 = Other (specify), 9 = Unknown (within first 2 hours after birth)
	Mode	Start Date	End Date	Comments
1.		__ __/__ __/__ __	__ __/__ __/__ __
2.		__ __/__ __/__ __	__ __/__ __/__ __
3.		__ __/__ __/__ __	__ __/__ __/__ __
4.		__ __/__ __/__ __	__ __/__ __/__ __
Comments:

C. glucose stability  No Info
Bedside screens	Date drawn	Time drawn	Value (mg/dL)	Comments
1. First glucose screen	__ __/__ __/__ __	:
2. If ABNL, first WNL	__ __/__ __/__ __	:
3. Highest glucose in first 24 hrs	__ __/__ __/__ __	:
4. Lowest glucose in first 24 hrs	__ __/__ __/__ __	:
5. Comments:

D.Bilirubin  No Info
Total Bilirubin	Date drawn	Time drawn	Value (mg/dL)	Comments
1. Highest bilirubin	_ _/_ _/_ _ _ _	:

E. Score for neonatal acute physiology (SNAP)
1 Transferred to a well baby setting (e.g. home, MIR, maternal room, foster care, etc.) ? 2 Transported-in or re-admit to NICU greater than 4 hours after birth? If one of the above boxes is checked then, DO NOT collect this information and check here  NA Otherwise please complete this table (Section H).
SNAP period begins with physical entry into the NICU, even if the baby first spent time in the Well Baby Nursery (for < 4 hours). Only indicate values for first 24 hours after birth Time of Entry into NICU ____:____
1. Lowest Mean Arterial Pressure	Time ___ :___	(Do not include blood pressures in the delivery room) Systolic _______ Diastolic _______ MAP = _________
2. Lowest Temperature	Time ___ : ___	(Do not record temps obtained by probe only) oF________ oC________ 9  Unknown 1  Axillary 2  Rectal 9  Unknown
3. Highest Mean Airway Pressure	Time ___ : ___	If baby was not on a ventilator during this period, score as “not done.” ____ ____ ____ mm Hg
4. Lowest PaO2	Time ___ : ___	If baby was not on supplemental O2 during this period, count as “not done.” ____ ____ ____ mm Hg
5. Highest FiO2	Time ___ : ___	You may need to obtain this value from the Respiratory Therapy or Nursing Notes. ____ ____ ____ mm Hg
6. Lowest Serum pH (free)	Time ___ : ___	(This may be obtained by arterial, venous, or capillary blood gas) ___________
7. Seizures		1  None 2  Single 3  Multiple
8. Urine Output		(Add up the total for the 24 hour period) _______ cc/24 hours
9. Comments

F.nursery admission  No Info
1. GA By Exam (Wks) ____ (wks) ____ (days) 9  Not Stated		Dubowitz Gestational Age Assessment _____ (wks) _____ (days) 9  Not Stated					3. Estimated GA 9  Not Stated 1 AGA 3  LGA 2 SGA 4  IUGR
4. HC __________ (cm)		Height/ Length ___________ (cm)		Weight __________ (gm)			7. Toxicology Screen 9  Not Stated Specify _________________ 1 Neg 2 Pos 9 Unknown
8. Blood Type 1 A+ 2 A- 3 B+ 4 B- 5 AB+ 6 AB- 7 O+ 8 O- 9 Unknown
9. Hepatitis B Vaccine Given: 1 Yes 2 No 9  Unknown						10. Surfactant Given 1 Yes 2 No 9  Unknown
11. Birth Trauma Noted  No Info			12. Problems/Impressions  No Info
	Bruising				Sepsis				Hypotension
	Laceration				PFC/PPHN				Hypoglycemia
	Brachial Plexus Injury (E.G., Erb’s Palsy)				RDS/HMD				Hypothermia
	Fractured Clavicle				MAS (Meconium Aspiration Syn.)				PDA (Patent Ductus Arteriosus)
	DIC (Disseminated Intravascular Coagulation)				Birth Asphyxia				Pneumothorax
	TTN (Transient Tachypnea of Newborn)				Other (specify) ________________				Other (specify) ________________
	Other (specify) ________________				Other (specify) ________________				Other (specify) ________________
13. Resuscitation in delivery room  No Info			14. Nutrition 1 Breast Only 2 Formula Only 3 Combination 9 Unknown
	Bag & Mask: 1 < 2 min 2 > 2 min
	Medications
	Chest compressions, duration ____ min.		15. Formula given at any time in the nursery? 1 Yes 2 No 9  Unknown If yes, how often? ________________________________ 9  Unknown Type of Formula 1  Soy 2  Cow’s milk 3  Elemental Formula 9  Unknown Name of formula ? _______________________________
	Intubation & ET suction for meconium
	Intubation & positive pressure ventilation		NG or OG feeds? 1 Yes 2 No 9  Unknown If yes, how often? _________________________________ 9  Unknown
	Describe Intubation: 1 Routine 2  Difficult 9  Unknown		17. Was a referral made to a lactation consultant? 1 Yes 2 No 3 NA 9  Unknown
Comments

J. Medical HISTORY  NO INFO
Includes the Discharge Diagnoses
Med Hx Codes: Refer to Appendix A for list of codes. Precision Codes: 1= Possible, 2= Probable, 3= R/O, 4= Definite, 9= Unknown * If ‘yes’ is checked for Medications, then complete Section N.
No.	Med Hx Code	Precision Code	Date Diagnosed	Date Resolved	Medications Given*
1.			_ _/_ _/_ _ _ _ 9  Unknown	__ __/__ __/__ __ __ __ 1  Ongoing 9  Unknown	1  Yes 2  No 9  Unknown
2.			_ _/_ _/_ _ _ _ 9  Unknown	__ __/__ __/__ __ __ __ 1  Ongoing 9  Unknown	1  Yes 2  No 9  Unknown
3.			_ _/_ _/_ _ _ _ 9  Unknown	__ __/__ __/__ __ __ __ 1  Ongoing 9  Unknown	1  Yes 2  No 9  Unknown
4.			_ _/_ _/_ _ _ _ 9  Unknown	__ __/__ __/__ __ __ __ 1  Ongoing 9  Unknown	1  Yes 2  No 9  Unknown
5.			_ _/_ _/_ _ _ _ 9  Unknown	__ __/__ __/__ __ __ __ 1  Ongoing 9  Unknown	1  Yes 2  No 9  Unknown
6.			_ _/_ _/_ _ _ _ 9  Unknown	__ __/__ __/__ __ __ __ 1  Ongoing 9  Unknown	1  Yes 2  No 9  Unknown
7.			_ _/_ _/_ _ _ _ 9  Unknown	__ __/__ __/__ __ __ __ 1  Ongoing 9  Unknown	1  Yes 2  No 9  Unknown
8.			_ _/_ _/_ _ _ _ 9  Unknown	__ __/__ __/__ __ __ __ 1  Ongoing 9  Unknown	1  Yes 2  No 9  Unknown
9.			_ _/_ _/_ _ _ _ 9  Unknown	__ __/__ __/__ __ __ __ 1  Ongoing 9  Unknown	1  Yes 2  No 9  Unknown
Comments

K. INFECTIONS  NO INFO
Infection Code: Refer to Appendix A for list of codes. Temperature: Record temperature if range is < 36.5oC (97.7oF) or > 38.0oC (100.4oF). Also complete Section N. If ‘yes’ is checked for Cultures, then complete Section L. If ‘yes’ is checked for Medications, then complete Section P.
No.	Infection Code	Date Diagnosed	Certainty of Dx	Duration	Temperature	Cultures	Medication
1.		_ _/_ _/_ _ _ _ 9  Unknown	1.  Lab 2.  Clinical 3.  Suspect 9.  Unknown	__ __ __ days 9  Unknown	oC______ oF______ 1.  No temp 999.  Unknown	1  Yes 2  No 9  Unknown	1  Yes 2  No 9  Unknown
2.		_ _/_ _/_ _ _ _ 9  Unknown	1.  Lab 2.  Clinical 3.  Suspect 9.  Unknown	__ __ __ days 9  Unknown	oC______ oF______ 1.  No temp 999.  Unknown	1  Yes 2  No 9  Unknown	1  Yes 2  No 9  Unknown
3.		_ _/_ _/_ _ _ _ 9  Unknown	1.  Lab 2.  Clinical 3.  Suspect 9.  Unknown	__ __ __ days 9  Unknown	oC______ oF______ 1.  No temp 999.  Unknown	1  Yes 2  No 9  Unknown	1  Yes 2  No 9  Unknown
4.		_ _/_ _/_ _ _ _ 9  Unknown	1.  Lab 2.  Clinical 3.  Suspect 9.  Unknown	__ __ __ days 9  Unknown	oC______ oF______ 1.  No temp 999.  Unknown	1  Yes 2  No 9  Unknown	1  Yes 2  No 9  Unknown
5.		_ _/_ _/_ _ _ _ 9  Unknown	1.  Lab 2.  Clinical 3.  Suspect 9.  Unknown	__ __ __ days 9  Unknown	oC______ oF______ 1.  No temp 999.  Unknown	1  Yes 2  No 9  Unknown	1  Yes 2  No 9  Unknown
6.		_ _/_ _/_ _ _ _ 9  Unknown	1.  Lab 2.  Clinical 3.  Suspect 9.  Unknown	__ __ __ days 9  Unknown	oC______ oF______ 1.  No temp 999.  Unknown	1  Yes 2  No 9  Unknown	1  Yes 2  No 9  Unknown
Comments:

L. CULTURES RELATED TO INFECTION  NO INFO
Source: 1 = blood, 2 = CSF, 3 = ear canal, 4 = nasal, 5 = sputum, 6 = stool, 7 = throat, 8 = urine, 88= other (specify in comments), 99= Unknown Refer No.: Please indicate the event number from the appropriate section (e.g. D2 – for Section D, #2).
No.	Refer No.	Date Cultured	Source	Results	Description (organisms, etc.)
1.		__ __/__ __/__ __ __ __ 9  Unknown		1.  No growth 3.  NL Flora 2.  Light growth 4. Positive 5.  Growth noted, not specified 99.  Unknown
2.		__ __/__ __/__ __ __ __ 9  Unknown		1.  No growth 3.  NL Flora 2.  Light growth 4. Positive 5.  Growth noted, not specified 99.  Unknown
3.		__ __/__ __/__ __ __ __ 9  Unknown		1.  No growth 3.  NL Flora 2.  Light growth 4. Positive 5.  Growth noted, not specified 99.  Unknown
4.		__ __/__ __/__ __ __ __ 9  Unknown		1.  No growth 3.  NL Flora 2.  Light growth 4. Positive 5.  Growth noted, not specified 99.  Unknown
5.		__ __/__ __/__ __ __ __ 9  Unknown		1.  No growth 3.  NL Flora 2.  Light growth 4. Positive 5.  Growth noted, not specified 99.  Unknown
6.		__ __/__ __/__ __ __ __ 9  Unknown		1.  No growth 3.  NL Flora 2.  Light growth 4. Positive 5.  Growth noted, not specified 99.  Unknown
7.		__ __/__ __/__ __ __ __ 9  Unknown		1.  No growth 3.  NL Flora 2.  Light growth 4. Positive 5.  Growth noted, not specified 99.  Unknown
8.		__ __/__ __/__ __ __ __ 9  Unknown		1.  No growth 3.  NL Flora 2.  Light growth 4. Positive 5.  Growth noted, not specified 99.  Unknown
9.		__ __/__ __/__ __ __ __ 9  Unknown		1.  No growth 3.  NL Flora 2.  Light growth 4. Positive 5.  Growth noted, not specified 99.  Unknown
10.		__ __/__ __/__ __ __ __ 9  Unknown		1.  No growth 3.  NL Flora 2.  Light growth 4. Positive 5.  Growth noted, not specified 99.  Unknown
Fc Comments

M. CSF ABNORMALITIES  NO INFO
1. Date __ __/__ __/__ __ __ __		2. Date __ __/__ __/__ __ __ __		3. Date __ __/__ __/__ __ __ __		4. Date __ __/__ __/__ __ __ __
Findings		Findings		Findings		Findings
	 WBC		 WBC		 WBC		 WBC
	 Protein		 Protein		 Protein		 Protein
	 Glucose		 Glucose		 Glucose		 Glucose
	 Gram stain		 Gram stain		 Gram stain		 Gram stain
	Other (specify): ____________________		Other (specify): ____________________		Other (specify): ____________________		Other (specify): ____________________

N. Temperature  NO INFO
Record temperatures < 36.5oC (97.7oF) or > 38.0oC (100.4oF). * If ‘yes’ is checked for Medications, then complete Section P.
No.	Date Started	Duration	Temp	Mode	Conditions	Action Taken	Medication Given*
1.	__ __/__ __/___ __ __	______ hours ______ days 9  Unk	________ 1  oC 2  oF	1  Skin 2  Axillary 3  Rectal 9  Unknown	1  Warmer 2  Isolette 9  Unknown	1  Bundled 2  Moved to warmer 3  Moved to isolette 4  Other (specify) _________________ 9  Unknown	1  Yes 2  No 9  Unknown
2.	__ __/__ __/___ __ __	______ hours ______ days 9  Unk	________ 1  oC 2  oF	1  Skin 2  Axillary 3  Rectal 9  Unknown	1  Warmer 2  Isolette 9  Unknown	1  Bundled 2  Moved to warmer 3  Moved to isolette 4  Other (specify) _________________ 9  Unknown	1  Yes 2  No 9  Unknown
3.	__ __/__ __/___ __ __	______ hours ______ days 9  Unk	________ 1  oC 2  oF	1  Skin 2  Axillary 3  Rectal 9  Unknown	1  Warmer 2  Isolette 9  Unknown	1  Bundled 2  Moved to warmer 3  Moved to isolette 4  Other (specify) _________________ 9  Unknown	1  Yes 2  No 9  Unknown
4.	__ __/__ __/___ __ __	______ hours ______ days 9  Unk	________ 1  oC 2  oF	1  Skin 2  Axillary 3  Rectal 9  Unknown	1  Warmer 2  Isolette 9  Unknown	1  Bundled 2  Moved to warmer 3  Moved to isolette 4  Other (specify) _________________ 9  Unknown	1  Yes 2  No 9  Unknown

O. SURGICAL HISTORY  NO INFO
* If ‘yes’ is checked for Medications or Anesthesia, then complete Section P. ** If temperature is < 36.5oC (97.7oF) or > 38.0oC (100.4oF), then complete Section N.
Circumcision 1  Yes 2  No 3  NA 9  Unknown (female)			Anesthesia* 1  Conscious Sedation 2  Local 3  Epidural 4  General 9  Unknown	Medications Given* 1  Yes 2  No 9  Unknown	Comments (e.g. type of injury)
Date __ __/__ __/__ __ __ __				Fever** 1  Yes 2  No 9  Unknown
Proc 1	CPT Code 9  Unknown	Date __ __/__ __/__ __ __ __	Anesthesia 1  Conscious Sedation 2  Local 3  Epidural 4  General 9  Unknown	Medications Given 1  Yes 2  No 9  Unknown	Comments (e.g. type of injury)
	Name of Procedure			Fever 1  Yes 2  No 9  Unknown
Proc 2	CPT Code 9  Unknown	Date __ __/__ __/__ __ __ __	Anesthesia 1  Conscious Sedation 2  Local 3  Epidural 4  General 9  Unknown	Medications Given 1  Yes 2  No 9  Unknown	Comments (e.g. type of injury)
	Name of Procedure			Fever 1  Yes 2  No 9  Unknown
Proc 3	CPT Code 9  Unknown	Date __ __/__ __/__ __ __ __	Anesthesia 1  Conscious Sedation 2  Local 3  Epidural 4  General 9  Unknown	Medications Given 1  Yes 2  No 9  Unknown	Comments (e.g. type of injury)
	Name of Procedure			Fever 1  Yes 2  No 9  Unknown

P. MEDICATIONS  NO INFO
Refer No.: Please indicate the event number from the appropriate section for Refer No., otherwise enter the reason from medical chart. Drug codes: 9= steroids (lung maturity) 10= antidiabetics, 11= steroids (other), 12= hormones, 13= thyroid, 14= antibiotics, 15= antifungals, 16= antivirals, 17= anesthetics, 18= anticonvulsants, 19= analgesics/hypnotics/sedatives/antipsychotics, 20 = antihypertensives/diuretics, 21= cardiovascular, 22= narcotic antagonists, 23= ergotrate, 24=antidepressants, 25= prenatal vitamins, 26= asthma, 27= preterm labor prevention,88= other (specify), 99= unknown Reason: Specify
	Refer No.	Code	Drug Name	Reason	Start Date/Time	Duration (in days)	Dose	Unit	Frequency
1					_ _ /_ _ /_ _ _ _ 9  Unknown	__________	__________  Variable	1  gm 2  mg 3  mcg 4  mU 5  cc/ml 8  other	1  QD 2  BID 3  TID 4  QID 5  PRN 6 Every ___ hrs 7  Per week 8  Total Dose 9  No Info
2					_ _ /_ _ /_ _ _ _ 9  Unknown	__________	__________  Variable	1  gm 2  mg 3  mcg 4  mU 5  cc/ml 8  other	1  QD 2  BID 3  TID 4  QID 5  PRN 6 Every ___ hrs 7  Per week 8  Total Dose 9  No Info
3					_ _ /_ _ /_ _ _ _ 9  Unknown	__________	__________  Variable	1  gm 2  mg 3  mcg 4  mU 5  cc/ml 8  other	1  QD 2  BID 3  TID 4  QID 5  PRN 6 Every ___ hrs 7  Per week 8  Total Dose 9  No Info
4					_ _ /_ _ /_ _ _ _ 9  Unknown	__________	__________  Variable	1  gm 2  mg 3  mcg 4  mU 5  cc/ml 8  other	1  QD 2  BID 3  TID 4  QID 5  PRN 6 Every ___ hrs 7  Per week 8  Total Dose 9  No Info
5					_ _ /_ _ /_ _ _ _ 9  Unknown	__________	__________  Variable	1  gm 2  mg 3  mcg 4  mU 5  cc/ml 8  other	1  QD 2  BID 3  TID 4  QID 5  PRN 6 Every ___ hrs 7  Per week 8  Total Dose 9  No Info
6					_ _ /_ _ /_ _ _ _ 9  Unknown	__________	__________  Variable	1  gm 2  mg 3  mcg 4  mU 5  cc/ml 8  other	1  QD 2  BID 3  TID 4  QID 5  PRN 6 Every ___ hrs 7  Per week 8  Total Dose 9  No Info
7					_ _ /_ _ /_ _ _ _ 9  Unknown	__________	__________  Variable	1  gm 2  mg 3  mcg 4  mU 5  cc/ml 8  other	1  QD 2  BID 3  TID 4  QID 5  PRN 6 Every ___ hrs 7  Per week 8  Total Dose 9  No Info
8					_ _ /_ _ /_ _ _ _ 9  Unknown	__________	__________  Variable	1  gm 2  mg 3  mcg 4  mU 5  cc/ml 8  other	1  QD 2  BID 3  TID 4  QID 5  PRN 6 Every ___ hrs 7  Per week 8  Total Dose 9  No Info

Q. Blood product transfusions  NO INFO
Exclude normal saline partial exchange transfusion for polycythemia and albumin infusions for hypotension
Total # 1 None 2  One 3  More than one
2. Reasons for transfusions
	Iatrogenic anemia		Thrombocytopenia		Hyperbilirubinemia
	Anemia of prematurity		DIC		Other (specify): _________________
	Other anemia (specify): _________________		Other clotting factor deficiency
3. Comments

R. NEUROLOGY CONSULTS  NO INFO
Neurology Codes: 1 = Birth asphyxia 2 = Brachial plexus injury 3 = Seizures 8 = Other (specify in comments)
Refer No.: Please indicate the event number from the appropriate section (e.g. D2 – for Section D, #2), otherwise enter the reason for consult. * If ‘yes’ is indicated for Medications Given, then please complete Section P.
1	Date: __ __/__ __/__ __ __ __	Refer No. or Reason	Neurology Code	Medication Given* 1  Yes 2  No 9  Unknown	Comments
2	Date: __ __/__ __/__ __ __ __	Refer No. or Reason	Neurology Code	Medication Given* 1  Yes 2  No 9  Unknown	Comments
3	Date: __ __/__ __/__ __ __ __	Refer No. or Reason	Neurology Code	Medication Given* 1  Yes 2  No 9  Unknown	Comments
4	Date: __ __/__ __/__ __ __ __	Refer No. or Reason	Neurology Code	Medication Given* 1  Yes 2  No 9  Unknown	Comments

S. SEIZURES  NO INFO
Proximate cause: 1 = Cranial bleed, 2 = Cranial trauma, 3 = Drug withdrawal, 4 = HIE, 5 = Immunization, 6 = Medication, 7 = Meningitis, 8 = Metabolic encephalopathy, 88 = Other(specify in comments), 9 = Unknown
1. Date __ __/__ __/__ __ __ ___	Time ____ : ___	Describe episode		Witnessed by
			Clonic/convulsive		RN
Proximate cause1			Tonic/posturing		MD
Proximate cause2			Myoclonic		Parent
Meds given (specify in Section P) 1 Yes 2 No 9 Unknown			Subtle		Other (specify): ________________
			Other (specify): __________________________
Comments
2. Date __ __/__ __/__ __ __ ___	Time ____ : ___	Describe episode		Witnessed by
			Clonic/convulsive		RN
Proximate cause1			Tonic/posturing		MD
Proximate cause2			Myoclonic		Parent
Meds given (specify in Section P) 1 Yes 2 No 9 Unknown			Subtle		Other (specify): ________________
			Other (specify): ___________________________
Comments
3. Date __ __/__ __/__ __ __ ___	Time ____ : ___	Describe episode		Witnessed by
			Clonic/convulsive		RN
Proximate cause1			Tonic/posturing		MD
Proximate cause2			Myoclonic		Parent
Meds given (specify in Section P) 1 Yes 2 No 9 Unknown			Subtle		Other (specify): ________________
			Other (specify): ___________________________
Comments

T. Cranial Ultrasounds  NO INFO
Please record all ultrasounds.
1. Date __ __/__ __/__ __ __ ___		Results 1 Normal 2 Abnormal 3 Equivocal		Hemisphere: 1 = Right, 2 = Left, 3 = Bilateral, 9 = Unknown Location: 1 = Anterior/Frontal, 2 = Posterior/Occipital, 3 = Parietal, 4 = Temporal, 9 = Unknown Size: 1 = Small/Mild, 2 = Medium/Moderate, 3 = Large/Severe, 9 = Unknown
Findings (1= No, 2= Definite, 3=Suspect)				H	L	S	Description/Comments
	Ventriculomegaly
	Echodensity/echogenicity
	Echolucency
	IVH grade _____
	Germinal matrix bleed (Grade I IVH)
	Other bleed
	PVL/cavitation/white matter necrosis
	Malformation
	Subarachnoid hemorrhage/blood
	Other findings (specify)
2. Date __ __/__ __/__ __ __ ___			Results 1 Normal 2 Abnormal 3 Equivocal	Hemisphere: 1 = Right, 2 = Left, 3 = Bilateral, 9 = Unknown Location: 1 = Anterior/Frontal, 2 = Posterior/Occipital, 3 = Parietal, 4 = Temporal, 9 = Unknown Size: 1 = Small/Mild, 2 = Medium/Moderate, 3 = Large/Severe, 9 = Unknown
Findings (1= No, 2= Definite, 3=Suspect)				H	L	S	Description/Comments
	Ventriculomegaly
	Echodensity/echogenicity
	Echolucency
	IVH grade _____
	Germinal matrix bleed (Grade I IVH)
	Other bleed
	PVL/cavitation/white matter necrosis
	Malformation
	Subarachnoid hemorrhage/blood
	Other findings (specify)

U. cranial studies (EEG, MRI and CT Scan)  NO INFO
Please abstract all ultrasounds. Code: 1 = EEG, 2 = Cranial MRI, 3 = CT scan, 8 = Other (specify in comments)
1. Date __ __/__ __/__ __ __ ___	Code	Results 1 Normal 3 Equivocal 2 Abnormal 9 Unknown	Final Impression	Comments
2. Date __ __/__ __/__ __ __ ___	Code	Results 1 Normal 3 Equivocal 2 Abnormal 9 Unknown	Final Impression	Comments
3. Date __ __/__ __/__ __ __ ___	Code	Results 1 Normal 3 Equivocal 2 Abnormal 9 Unknown	Final Impression	Comments

V. OTHER Procedure or study (ECG, Chest X-ray, Genetic Study, etc.)  NO INFO
Refer No.: Please indicate the event number from the appropriate section (e.g. D2 – for Section D, #2), otherwise enter the reason from the chart.
	Refer No./ Reason	Type of Procedure	Date	Outcome
1.			_ _/_ _/_ _ _ _
2.			_ _/_ _/_ _ _ _
3.			_ _/_ _/_ _ _ _
4.			_ _/_ _/_ _ _ _
5.			_ _/_ _/_ _ _ _

W. Disposition at Final discharge  No Info
1. Date of DC __ __/__ __/__ __ __ ___		2. HC ______ (cm) ______ (in)			3. Height/ Length ______ (cm) ______ (in)		4. Weight _____ (gm) _____ (lbs)		5. Discharged to: 1 Home with biological parent(s) 2 Foster care 3 Adopted 4 Custodial care 8 Other (specify) ______________________
Medications at Discharge 1 Yes (Fill out Section P) 2  No
7. Referrals  No Info
	Routine pediatrician appointment			Home health nurse home visit(s)						Ophthalmology follow-up
	Audiology follow-up			High-risk infant follow-up clinic						Public health home visit(s)
	Nutritional support 1 Bottle 2 Breast 3 Breast and Bottle 4 Tube 8 Other (specify) __________________			Respiratory support 1 Oxygen 2 Respiratory support 3 Apnea monitor 8 Other (specify) __________________________						Other (specify) _________________________
8. Seizure status at time of discharge						9. Comments
1 No history of seizures 2 Controlled with meds 3 Resolved, not under treatment 4 Unresolved, still under treatment 9 Unknown

Appendix S4