Appendix_S

Study ID Number

Study to Explore Early Development

Neonatal / birth hospital Chart Medical Record

Abstraction Form

This form should be used for abstraction of medical records from the hospital of delivery and early neonatal care (first 28 days of life).

Note: there may be more than one if there was a neonatal transport.

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 __ __: __ __ Start __ __ : __ __ Stop __ __: __ __	A.7.1 to A.7.8 Time (*use military time) Start __ __ : __ __ Stop __ __: __ __ Start __ __ : __ __ Stop __ __: __ __ Start __ __ : __ __ Stop __ __: __ __ Start __ __ : __ __ Stop __ __: __ __		A.8.1 to A.8.8 Time (*use military time) Start __ __ : __ __ Stop __ __: __ __ 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 __ __: __ __ Start __ __ : __ __ Stop __ __: __ __	A.10.1 to A.10.8 Time (*use military time) Start __ __ : __ __ Stop __ __: __ __ Start __ __ : __ __ Stop __ __: __ __ Start __ __ : __ __ Stop __ __: __ __ Start __ __ : __ __ Stop __ __: __ __		A.11.1 to A.11.8 Time (*use military time) Start __ __ : __ __ Stop __ __: __ __ 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 __ __: __ __ Start __ __ : __ __ Stop __ __: __ __	B.7.1 to B.7.8 Time (*use military time) Start __ __ : __ __ Stop __ __: __ __ Start __ __ : __ __ Stop __ __: __ __ Start __ __ : __ __ Stop __ __: __ __ Start __ __ : __ __ Stop __ __: __ __		B.8.1 to B.8.8 Time (*use military time) Start __ __ : __ __ Stop __ __: __ __ 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 __ __: __ __ Start __ __ : __ __ Stop __ __: __ __	B.10.1 to B.10.8 Time (*use military time) Start __ __ : __ __ Stop __ __: __ __ Start __ __ : __ __ Stop __ __: __ __ Start __ __ : __ __ Stop __ __: __ __ Start __ __ : __ __ Stop __ __: __ __		B.11.1 to B.11.8 Time (*use military time) Start __ __ : __ __ Stop __ __: __ __ Start __ __ : __ __ Stop __ __: __ __ Start __ __ : __ __ Stop __ __: __ __ Start __ __ : __ __ Stop __ __: __ __
C.1. Name of Provider/Hospital
C.2. Street Address
C.3. City		C.4. State		C.5. Zip Code
ABSTRACTION LOG
C.6. Date __ __/__ __/__ __ __ __	C.7. Date __ __/__ __/__ __ __ __		C.8. Date __ __/__ __/__ __ __ __
C.6.1 to C.6.8 Time (*use military time) Start __ __ : __ __ Stop __ __: __ __ Start __ __ : __ __ Stop __ __: __ __ Start __ __ : __ __ Stop __ __: __ __ Start __ __ : __ __ Stop __ __: __ __	C.71 to C.7.8 Time (*use military time) Start __ __ : __ __ Stop __ __: __ __ Start __ __ : __ __ Stop __ __: __ __ Start __ __ : __ __ Stop __ __: __ __ Start __ __ : __ __ Stop __ __: __ __		C.8.1 to C.8.8 Time (*use military time) Start __ __ : __ __ Stop __ __: __ __ Start __ __ : __ __ Stop __ __: __ __ Start __ __ : __ __ Stop __ __: __ __ Start __ __ : __ __ Stop __ __: __ __
C.9. Date __ __/__ __/__ __ __ __	C.10. Date __ __/__ __/__ __ __ __		C.11. Date __ __/__ __/__ __ __ __
C.9.1 to C.9.8 Time (*use military time) Start __ __ : __ __ Stop __ __: __ __ Start __ __ : __ __ Stop __ __: __ __ Start __ __ : __ __ Stop __ __: __ __ Start __ __ : __ __ Stop __ __: __ __	C.10.1 to C.10.8 Time (*use military time) Start __ __ : __ __ Stop __ __: __ __ Start __ __ : __ __ Stop __ __: __ __ Start __ __ : __ __ Stop __ __: __ __ Start __ __ : __ __ Stop __ __: __ __		C.11.1 to C.11.8 Time (*use military time) Start __ __ : __ __ Stop __ __: __ __ Start __ __ : __ __ Stop __ __: __ __ Start __ __ : __ __ Stop __ __: __ __ Start __ __ : __ __ Stop __ __: __ __
D.1. Name of Provider/Hospital
D.2. Street Address
D.3. City		D.4. State		D.5. Zip Code
ABSTRACTION LOG
D.6. Date __ __/__ __/__ __ __ __	D.7. Date __ __/__ __/__ __ __ __		D.8. Date __ __/__ __/__ __ __ __
D.6.1 to D.6.8 Time (*use military time) Start __ __ : __ __ Stop __ __: __ __ Start __ __ : __ __ Stop __ __: __ __ Start __ __ : __ __ Stop __ __: __ __ Start __ __ : __ __ Stop __ __: __ __	D.71 to D.7.8 Time (*use military time) Start __ __ : __ __ Stop __ __: __ __ Start __ __ : __ __ Stop __ __: __ __ Start __ __ : __ __ Stop __ __: __ __ Start __ __ : __ __ Stop __ __: __ __		D.8.1 to D.8.8 Time (*use military time) Start __ __ : __ __ Stop __ __: __ __ Start __ __ : __ __ Stop __ __: __ __ Start __ __ : __ __ Stop __ __: __ __ Start __ __ : __ __ Stop __ __: __ __
D.9. Date __ __/__ __/__ __ __ __	D.10. Date __ __/__ __/__ __ __ __		D.11. Date __ __/__ __/__ __ __ __
D.9.1 to D.9.8 Time (*use military time) Start __ __ : __ __ Stop __ __: __ __ Start __ __ : __ __ Stop __ __: __ __ Start __ __ : __ __ Stop __ __: __ __ Start __ __ : __ __ Stop __ __: __ __	D.10.1 to D.10.8 Time (*use military time) Start __ __ : __ __ Stop __ __: __ __ Start __ __ : __ __ Stop __ __: __ __ Start __ __ : __ __ Stop __ __: __ __ Start __ __ : __ __ Stop __ __: __ __		D.11.1 to D.11.8 Time (*use military time) Start __ __ : __ __ Stop __ __: __ __ Start __ __ : __ __ Stop __ __: __ __ Start __ __ : __ __ Stop __ __: __ __ Start __ __ : __ __ Stop __ __: __ __
E.1. Name of Provider/Hospital
E.2. Street Address
E.3. City		E.4. State		E.5. Zip Code
ABSTRACTION LOG
E.6. Date __ __/__ __/__ __ __ __	E.7. Date __ __/__ __/__ __ __ __		E.8. Date __ __/__ __/__ __ __ __
E.6.1 to E.6.8 Time (*use military time) Start __ __ : __ __ Stop __ __: __ __ Start __ __ : __ __ Stop __ __: __ __ Start __ __ : __ __ Stop __ __: __ __ Start __ __ : __ __ Stop __ __: __ __	E.71 to E.7.8 Time (*use military time) Start __ __ : __ __ Stop __ __: __ __ Start __ __ : __ __ Stop __ __: __ __ Start __ __ : __ __ Stop __ __: __ __ Start __ __ : __ __ Stop __ __: __ __		E.8.1 to E.8.8 Time (*use military time) Start __ __ : __ __ Stop __ __: __ __ Start __ __ : __ __ Stop __ __: __ __ Start __ __ : __ __ Stop __ __: __ __ Start __ __ : __ __ Stop __ __: __ __
E9. Date __ __/__ __/__ __ __ __	E10. Date __ __/__ __/__ __ __ __		E11. Date __ __/__ __/__ __ __ __
E9.1 to D.9.8 Time (*use military time) Start __ __ : __ __ Stop __ __: __ __ Start __ __ : __ __ Stop __ __: __ __ Start __ __ : __ __ Stop __ __: __ __ Start __ __ : __ __ Stop __ __: __ __	E10.1 to E10.8 Time (*use military time) Start __ __ : __ __ Stop __ __: __ __ Start __ __ : __ __ Stop __ __: __ __ Start __ __ : __ __ Stop __ __: __ __ Start __ __ : __ __ Stop __ __: __ __		E11.1 to E11.8 Time (*use military time) Start __ __ : __ __ Stop __ __: __ __ Start __ __ : __ __ Stop __ __: __ __ Start __ __ : __ __ Stop __ __: __ __ Start __ __ : __ __ Stop __ __: __ __

(Add extra sheets as needed)

A. identifying Information No information for any item in section
Baby’s Name (Last, First, Middle, Suffix)
Baby AKA		3. Date of birth _ _/_ _/_ _ _ _		4. Time of Birth _ _ : _ _
5. Mother’s Name (Last, First, Middle)		6. Mother’s Maiden Name
7. Street Address		8. City		9. State		10. Zip Code
11. Birth Hospital Name
12. Hospital Address		13. City		14. State	15. Zip code
16. Father’s Name (Last, First, Middle)
17. Time @ 4-hour Age 17a. Date _ _/_ _/_ _ _ _ 17b. Time _ _:_ _	18. Time @ 12-hour Age 18a. Date _ ­_/_ _/_ _ _ _ 18b. Time _ _ : _ _		19.Time @ 24-hour Age 19a. Date _ _/_ _/_ _ _ _ 19b. Time _ _:_ _	20. Time @ 48-hour Age 20a. Date _ _/_ _/_ _ _ _ 20b. Time _ _ : _ _
21. Comments:

Sections B-W: 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

77. NA

88. 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. Infant Transport No information for any item in section Test/procedure for one or more items in section indicated but no information on dates, results, etc.
FIRST INFANT TRANSPORT
1a. Name of Receiving Hospital	1b. Date Arrived _ _/_ _/_ _ _ _	1c. Date Departed _ _/_ _/_ _ _ _	1d. Transport Service 1 Ambulance 2 Helicopter 3 Private car 8 Other (specify) ____________________1d.sp. 88 IL 99 NR
1e. Reason for Transport:
SECOND INFANT TRANSPORT
2a. Name of Receiving Hospital	2b. Date Arrived _ _/_ _/_ _ _ _	2c. Date Departed _ _/_ _/_ _ _ _	2d. Transport Service 1 Ambulance 2 Helicopter 3 Private car 8 Other (specify) ____________________2d.sp. 88 IL 99 NR
2e. Reason for Transport
THIRD INFANT TRANSPORT
3a. Name of Receiving Hospital	3b. Date Arrived _ _/_ _/_ _ _ _	3c. Date Departed _ _/_ _/_ _ _ _	3d. Transport Service 1 Ambulance 2 Helicopter 3 Private car 8 Other (specify) ____________________3d.sp. 88 IL 99 NR
3e. Reason for Transport:

C. temperatures No information for any item in section
1. Initial temp (nursery admit) ______.______ 1a. Units: 1 oC 2 oF 88 IL 99 NR 1b. Mode: 1 Skin 2 Axillary 3 Rectal 88 IL 99 NR				2. Initial temp date __ __/__ __/__ __ __ __		3. Initial temp time __ __ : __ __
4. Lowest temp in first 48 hrs ______.______ 4a. Units: 1 oC 2 oF 88 IL 99 NR 4b. Mode: 1 Skin 2 Axillary 3 Rectal 88 IL 9 NR				5. Highest temp in first 48 hrs ______.______ 5a. Units: 1 oC 2 oF 88 IL 99 NR 5b. Mode: 1 Skin 2 Axillary 3 Rectal 88 IL 99 NR
6. Comments:
d. First BABY gases (within first 2 hours after birth) No information for any item in section Test/procedure for one or more items in section indicated but no information on dates, results, etc.
	Time drawn	Type	pH		Base Excess/Base Deficit
1.	1a. __ __ : __ __	1b. 1 Arterial/ABG 2 Venous/VBG 88 Illegible 99 Not Recorded	1c.		1d.
2.	2a. __ __ : __ __	2b. 1 Arterial/ABG 2 Venous/VBG 88 Illegible 99 Not Record	2c.		2d.
3.	3a. __ __ : __ __	3b. 1 Arterial/ABG 2 Venous/VBG 88 Illegible 99 Not Recorded	3c.		3d.
4.	4a. __ __ : __ __	4b. 1 Arterial/ABG 2 Venous/VBG 88 Illegible 99 Not Recorded	4c.		4d.
5. Comments:

E. Respiratory support (within first 2 hours after birth) No information for any item in section Test/procedure for one or more items in section indicated but no information on dates, results, etc.
Mode of respiratory support: 1 = IMV, 2 = (N)CPAP, 3 = Oxy hood, 4 = NC, 5 = HFV, 6 = Nitric Oxide, 8 = Other (specify in comments), 88 = Illegible, 99 = Not Recorded
	Mode	Start Time	End Time	Duration	Comments
1.	1a.	1b. __ __ : __ __	1c. __ __ : __ __	1d. _ _ : _ _ : _ _ hrs min sec	1e.
2.	2a.	2b. __ __ : __ __	2c. __ __ : __ __	2d. _ _ : _ _ : _ _ hrs min sec	2e.
3.	3a.	3b. __ __ : __ __	3c. __ __ : __ __	3d. _ _ : _ _ : _ _ hrs min sec	3e.
4.	4a.	4b. __ __ : __ __	4c. __ __ : __ __	4d. _ _ : _ _ : _ _ hrs min sec	4e.
5. Comments:

F. glucose stability (within first 24 hours after birth) No information for any item in section Test/procedure for one or more items in section indicated but no information on dates, results, etc.
Screens	Date Drawn	Time Drawn	Value	Associated Clinical Symptoms
1. First glucose screen	1a. __ __/__ __/__ __	1b. __ __ : __ __	1c. ___________ 1c.1. Units: 1 mg/dL 2 mmol/L 88 IL 99 NR	1d. (Check all that apply) 1d.1. 1 Jitters 1d.2. 2 Seizures 1d.3. 3 Shock 1d.4. 4 Apnea 1d.5. 5 Decreased Perfusion 1d.6. 8 Other (specify) ___________1d.6.sp. 1d.7 88 IL 1d.8 99 NR
2. If ABNL, first WNL	2a. __ __/__ __/__ __	2b. __ __ : __ __	2c. ___________ 2c.1. Units: 1 mg/dL 2 mmol/L 88 IL 99 NR	2d. (Check all that apply) 2d.1. 1 Jitters 2d.2. 2 Seizures 2d.3. 3 Shock 2d.4. 4 Apnea 2d.5. 5 Decreased Perfusion 2d.6. 8 Other (specify) ___________2d.6.sp. 2d.7 88 IL 2d.8 99 NR
3. Highest glucose in first 24 hrs	3a. __ __/__ __/__ __	3b. __ __ : __ __	3c. ___________ 3c.1. Units: 1 mg/dL 2 mmol/L 88 IL 99 NR	3d. (Check all that apply) 3d.1. 1 Jitters 3d.2. 2 Seizures 3d.3. 3 Shock 3d.4. 4 Apnea 3d.5. 5 Decreased Perfusion 3d.6. 8 Other (specify) ___________3d.6.sp. 3d.7 88 IL 3d.8 99 NR
4. Lowest glucose in first 24 hrs	4a. __ __/__ __/__ __	4b. __ __ : __ __	4c. ___________ 4c.1. Units: 1 mg/dL 2 mmol/L 88 IL 99 NR	4d. (Check all that apply) 4d.1. 1 Jitters 4d.2. 2 Seizures 4d.3. 3 Shock 4d.4. 4 Apnea 4d.5. 5 Decreased Perfusion 4d.6. 8 Other (specify) ___________4d.6.sp. 4d.7 88 IL 4d.8 99 NR
5. Comments:

G. Bilirubin (Collect all values) No information for any item in section Test/procedure for one or more items in section indicated but no information on dates, results, etc.
Date Drawn	Time Drawn	Value	Treatment (check all that apply)	Antibody Reaction (check all that apply)
1. _ _ / _ _ / _ _ _ _	1a. __ __ : __ __	1b. 1b.1. Total ______ 1b.2. Direct _____ _­ 1b.3. Indirect_____ 1b.4. Units 1 mg/dL 2 mmol/L 88 IL 99 NR	1c. 1c.1. 1 IV Fluids 1c.2. 2 Photo Therapy 1c.3. 3Exchange Transfusion 1c.4. 4 None 1c.5. 88 IL 1c.6. 99 NR	1d. 1d.1. 1 Coombs Test → 1d.1a. 1 Positive 1d.1b. 2 Negative 1d.2. 2 Rh Sensitivity 1d.3. 3 Blood Type Antibody Tests 1d.4. 4 None 1d.5. 8 Other (specify) _____________1d.5.sp. 1d.6. 88 IL 1d.7. 99 NR
1e. Comments:
2. _ _ / _ _ / _ _ _ _	2a. __ __ : __ __	2b. 2b.1. Total ______ 2b.2. Direct _____ _­ 2b.3. Indirect_____ 2b.4. Units 1 mg/dL 2 mmol/L 88 IL 99 NR	2c. 2c.1. 1 IV Fluids 2c.2. 2 Photo Therapy 2c.3. 3Exchange Transfusion 2c.4. 4 None 2c.5. 88 IL 2c.6. 99 NR	2d. 2d.1. 1 Coombs Test → 2d.1a. 1 Positive 2d.1b. 2 Negative 2d.2. 2 Rh Sensitivity 2d.3. 3 Blood Type Antibody Tests 2d.4. 4 None 2d.5. 8 Other (specify) _____________1d.5.sp. 2d.6. 88 IL 2d.7. 99 NR
2e. Comments:
3. _ _ / _ _ / _ _ _ _	3a. __ __ : __ __	3b. 3b.1. Total ______ 3b.2. Direct _____ _­ 3b.3. Indirect_____ 3b.4. Units 1 mg/dL 2 mmol/L 88 IL 99 NR	3c. 3c.1. 1 IV Fluids 3c.2. 2 Photo Therapy 3c.3. 3Exchange Transfusion 3c.4. 4 None 3c.5. 88 IL 3c.6. 99 NR	3d. 3d.1. 1 Coombs Test → 3d.1a. 1 Positive 3d.1b. 2 Negative 3d.2. 2 Rh Sensitivity 3d.3. 3 Blood Type Antibody Tests 3d.4. 4 None 3d.5. 8 Other (specify) _____________1d.5.sp. 3d.6. 88 IL 3d.7. 99 NR
3e. Comments:

H. Score for neonatal acute physiology (SNAP) No information for any item in section Test/procedure for one or more items in section indicated but no information on dates, results, etc.
1. 1a.  Transferred to a well baby setting (e.g. home, Maternal-Infant bonding room, maternal room, foster care, etc.)? 1b.  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 the information below and check here: 1c. 77 NA Otherwise please complete the information below.
**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** 1d. Date of Entry into NICU __ __/__ __/__ __ __ __ 1e. Time of Entry into NICU ____:____
2. Lowest Mean Arterial Pressure	2a. Date: _ _/_ _/_ _ _ _ 2b. Time: ___ :___	2c. Do not include blood pressures in the delivery room 2c.1 Systolic _______ 2c.2 Diastolic _______ 2c.3 MAP (from chart) = _______ 2c.4 MAP (calculated) = _______
3. Lowest Temperature	3a. Date: _ _/_ _/_ _ _ _ 3b. Time: ___ :___	Do not record temps obtained by probe only 3c. ________ 3d. Units: 1 oC 2 oF 88 IL 99 NR 3e. Mode: 1 Axillary 2 Rectal 88 IL 99 NR
4. Highest Mean Airway Pressure	4a. Date: _ _/_ _/_ _ _ _ 4b. Time: ___ :___	If baby was not on a ventilator during this period, score as “not done.” 4c. ____ ____ ____ mm Hg 4d.  Not Done
5. Lowest PaO2	5a. Date: _ _/_ _/_ _ _ _ 5b. Time: ___ :___	If baby was not on supplemental O2 during this period, count as “not done.” 5c. ____ ____ ____ mm Hg 5d.  Not Done
6. Highest FiO2	6a. Date: _ _/_ _/_ _ _ _ 6b. Time: ___ :___	You may need to obtain this value from the Respiratory Therapy or Nursing Notes. 6c. ____ ____ ____ mm Hg 88 IL 99 NR
7. Lowest Serum pH (free)	7a. Date: _ _/_ _/_ _ _ _ 7b. Time: ___ :___	This may be obtained by arterial, venous, or capillary blood gas. (Do NOT include cord gases) 7c. _____________________ 88 IL 99 NR
8. Seizures		1 None 2 Single 3 Multiple 88 IL 99 NR
9. Urine Output		_______ cc/24 hours (Add up the total for the 24 hour period)
10. Comments:

I. Baby admission No information for any item in section Test/procedure for one or more items in section indicated but no information on dates, results, etc.
1. GA By Exam (Wks) 1a. ____ (wks) 1b. ____ (days)	Dubowitz Gestational Age Assessment 2a. ____ (wks) 2b. ____ (days)			3. Estimated Gestational Age 1 AGA 2 SGA 3 LGA 4 IUGR 88 IL 99 NR
4. Head Circumference #__________ (cm)	5. Height/ Length #___________ (cm)		6. Weight #__________ (gm)	7. Hepatitis B Vaccine Given: 1 Yes 2 No 88 IL 99 NR
Blood Type 1 A+ 2 A- 3 B+ 4 B- 5 AB+ 6 AB- 7 O+ 8 O- 88 IL 99 NR						9. Rh Type 1 Negative 2 Positive 88 IL 99 NR
10. Toxicology Screen: 1 Yes* 2 No 88 IL 99 NR *(specify type)_____________________ 10.sp.		10a. Results: 1 Positive (specify result) ___________________________10a.sp. 2 Negative 77 NA 88 IL 99 NR				11. Surfactant Given 1 Yes 2 No 88 IL 99 NR
12. Birth Trauma Noted (check all that apply)		13. Problems/Impressions (check all that apply)
12a. 1 Bruising 12b. 2 Laceration 12c. 3 Brachial Plexus Injury (e.g., Erb’s Palsy) 12d. 4 Fractured Clavicle 12e. 5 DIC 12f. 6 TTN 12g. 8 Other (specify trauma) __________________________12g.sp. 12h. 88 IL 12i. 99 NR		13a. 1 Birth Asphyxia 13b . 2 Hypoglycemia 13c. 3 Hypothermia 13d. 4 Hypotension 13e. 5 MAS 13f. 6 PDA 13g. 7 PFC/PPHN 13h. 8 Pneumothorax			13i. 9 RDS/HMD 13j. 10 Sepsis 13k. 11 Other (specify problem) _______________________________13k.sp. 13l. 12 Other (specify problem) _______________________________13l.sp. 13m. 88 IL 13n. 99 NR
14. Resuscitation in delivery room (check all that apply)		15. Nutrition
14a. 1 Bag & Mask: 14a.1. 1 < 2 min 2 > 2 min 14b. 2 Intubation & ET suction for Meconium* (14b.1. below) 14c. 3 Intubation & positive pressure Ventilation* (14c.1. below) 14d. 4 Medications (fill out Section P) 14e. 5 Chest compressions: 14e.1. Duration: ____ minutes 14f. 88 IL 14g. 99 NR		15a. 1 Breast Only 15b. 2 Formula Only 15c. 3 Combination (specify)____________________ 15c.sp. 15d. 4 Tube 15e. 8 Other (specify)_____________________________ 15e.sp. 15f. 88 IL 15g. 99 NR
		16. Formula No information for any item in section
		16a.1. Was formula given at anytime in the nursery/during stay? 1 Yes* 2 No 88 IL 99 NR *If yes, how often? Every ______ hours - 16a.sp. 16a.2 Type of Formula 1 Soy 2 Cow’s milk 3 Elemental Formula* *Name of formula? (verbatim from record) __________________________________________________________ 16a.2.sp. 88 IL 99 NR
* Describe Intubation (as described in chart): 14b.1. 1 Routine 2 Difficult 88 IL 9 NR 14c.1. 1 Routine 2 Difficult 88 IL 99 NR
17. NG or OG feeds		18. Was a referral made to a lactation consultant?
1 Yes* 2 No 88 IL 99 NR 17a.sp. *How often? Every ______ hours 88 IL 99 NR		1 Yes 2 No 77 NA 88 IL 99 NR
		19. Comments

J. Medical HISTORY No information for any item in section
Includes the Discharge Diagnoses
Med Hx Codes: Refer to Appendix A for list of codes. Precision Codes: 1 = Suspected, 2 = Definite, 88 = Not Legible, 99 = Not Recorded * If ‘yes’ is checked for Medications, then complete Section P.
No.	Med Hx Code	Precision Code	Date Diagnosed	Date Resolved	Medications Given*
1.	1a.	1b.	1c. _ _/_ _/_ _ _ _ 9 Unknown	1d. __ __/__ __/__ __ __ __ 1 Ongoing 9 Unknown	1e. 1 Yes 2 No 88 IL 99 NR
	Specify: 1a.sp.
2.	2a.	2b.	2c. _ _/_ _/_ _ _ _ 9 Unknown	2d. __ __/__ __/__ __ __ __ 1 Ongoing 9 Unknown	2e. 1 Yes 2 No 88 IL 99 NR
	Specify: 2a.sp.
3.	3a.	3b.	3c. _ _/_ _/_ _ _ _ 9 Unknown	3d. __ __/__ __/__ __ __ __ 1 Ongoing 9 Unknown	3e. 1 Yes 2 No 88 IL 99 NR
	Specify: 3a.sp.
4.	4a.	4b.	4c. _ _/_ _/_ _ _ _ 9 Unknown	4d. __ __/__ __/__ __ __ __ 1 Ongoing 9 Unknown	4e. 1 Yes 2 No 88 IL 99 NR
	Specify: 4a.sp.
5.	5a.	5b.	5c. _ _/_ _/_ _ _ _ 9 Unknown	5d. __ __/__ __/__ __ __ __ 1 Ongoing 9 Unknown	5e. 1 Yes 2 No 88 IL 99 NR
	Specify: 5a.sp.
6.	6a.	6b.	6c. _ _/_ _/_ _ _ _ 9 Unknown	6d. __ __/__ __/__ __ __ __ 1 Ongoing 9 Unknown	6e. 1 Yes 2 No 88 IL 99 NR
	Specify: 6a.sp.
7.	7a.	7b.	7c. _ _/_ _/_ _ _ _ 9 Unknown	7d. __ __/__ __/__ __ __ __ 1 Ongoing 9 Unknown	7e. 1 Yes 2 No 88 IL 99 NR
	Specify: 7a.sp.
8.	8a.	8b.	8c. _ _/_ _/_ _ _ _ 9 Unknown	8d. __ __/__ __/__ __ __ __ 1 Ongoing 9 Unknown	8e. 1 Yes 2 No 88 IL 99 NR
	Specify: 8a.sp.
9.	9a.	9b.	9c. _ _/_ _/_ _ _ _ 9 Unknown	9d. __ __/__ __/__ __ __ __ 1 Ongoing 9 Unknown	9e. 1 Yes 2 No 88 IL 99 NR
	Specify 9a.sp.
10. Comments:

K. INFECTIONS No information for any item in section
Infection Code: Refer to Table 2 for list of codes. Temperature: Record the temperature if the 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	Highest Temperature	Culture/ Rapid Screen	Medication
1.	1a. ________ 1.a.sp. ________	1b. _ _/_ _/_ _ _ _	1c. 1 Lab / Test* 2 Clinical 3 Suspect 88 IL 99 NR * see manual	1d. __ __ __ days	1e. Value: _________ 7 Out of range 1e.1. Units: 1 oC 2 oF 88 IL 99 NR	1f. 1 Yes 2 No 88 IL 99 NR	1g. 1 Yes 2 No 88 IL 99 NR
2.	2a. ________ 2.a.sp. ________	2b. _ _/_ _/_ _ _ _	2c. 1 Lab / Test* 2 Clinical 3 Suspect 88 IL 99 NR * see manual	2d. __ __ __ days	2e. Value: _________ 7 Out of range 2e.1. Units: 1 oC 2 oF 88 IL 99 NR	2f. 1 Yes 2 No 88 IL 99 NR	2g. 1 Yes 2 No 88 IL 99 NR
3.	3a. ________ 3.a.sp. ________	3b. _ _/_ _/_ _ _ _	3c. 1 Lab / Test* 2 Clinical 3 Suspect 88 IL 99 NR * see manual	3d. __ __ __ days	3e. Value: _________ 7 Out of range 3e.1. Units: 1 oC 2 oF 88 IL 99 NR	3f. 1 Yes 2 No 88 IL 99 NR	3g. 1 Yes 2 No 88 IL 99 NR
4.	4a. ________ 4.a.sp. ________	4b. _ _/_ _/_ _ _ _	4c. 1 Lab / Test* 2 Clinical 3 Suspect 88 IL 99 NR * see manual	4d. __ __ __ days	4e. Value: _________ 7 Out of range 4e.1. Units: 1 oC 2 oF 88 IL 99 NR	4f. 1 Yes 2 No 88 IL 99 NR	4g. 1Yes 2 No 88 IL 99 NR
5.	5a. ________ 5.a.sp. ________	5b. _ _/_ _/_ _ _ _	5c. 1 Lab / Test* 2 Clinical 3 Suspect 88 IL 99 NR * see manual	5d. __ __ __ days	5e. Value: _________ 7 Out of range 5e.1. Units: 1 oC 2 oF 88 IL 99 NR	5f. 1 Yes 2 No 88 IL 99 NR	5g. 1 Yes 2 No 88 IL 99 NR
6. Comments:

L. CULTURES/RAPID STREP SCREENS RELATED TO INFECTION 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 = blood, 2 = CSF, 3 = ear canal, 4 = nasal, 5 = sputum, 6 = stool, 7 = throat, 8 = urine, 9 = skin, 10 = eye, 11 = intravenous/broviac line, 12 = endotracheal tube aspirate, 88 = other (specify), 888 = Not Legible, 99 = Not Recorded REF: Indicate the letter and number of the event from the previous section (e.g. K2 – for Section K, #2), otherwise enter the reason from the chart.

No.

REF

Date Cultured / Rapid Screen

Source

Results

Description (e.g. organisms in screen)

1.

1a. _______

1b. __ __/__ __/__ __ __ __

1c. ____________ 1.c.sp. ____________

1d. 1 No growth 2 Normal flora 3 Light growth 4 Moderate to heavy growth 5 Growth noted, not specified 6 Urine Culture colony count (Specify) __________1d.1.sp. 7 Rapid strep screen beta strep positive. 8 Rapid strep screen beta strep negative. 9 Other (Specify) __________________1d.2.sp. 77 NA 88 IL 99 NR

1e.

2.

2a. _______

2b. __ __/__ __/__ __ __ __

2c. ____________ 2.c.sp. ____________

2d. 1 No growth 2 Normal flora 3 Light growth 4 Moderate to heavy growth 5 Growth noted, not specified 6 Urine Culture colony count (Specify) __________2d.1.sp. 7 Rapid strep screen beta strep positive. 8 Rapid strep screen beta strep negative. 9 Other (Specify) __________________2d.2.sp. 77 NA 88 IL 99 NR

2e.

3.

3a. _______

3b. __ __/__ __/__ __ __ __

3c. ____________ 3.c.sp. ____________

3d. 1 No growth 2 Normal flora 3 Light growth 4 Moderate to heavy growth 5 Growth noted, not specified 6 Urine Culture colony count (Specify) __________3d.1.sp. 7 Rapid strep screen beta strep positive. 8 Rapid strep screen beta strep negative. 9 Other (Specify) __________________3d.2.sp. 77 NA 88 IL 99 NR

3e.

Fc 4. Comments:

M. CSF ABNORMALITIES No information for any item in section Test/procedure for one or more items in section indicated but no information on dates, results, etc.

1. Date __ __/__ __/__ __ __ __

2. Date __ __/__ __/__ __ __ __

3. Date __ __/__ __/__ __ __ __

4. Date __ __/__ __/__ __ __ __

1a. Findings (check all that apply)

2a. Findings (check all that apply)

3a. Findings (check all that apply)

4a. Findings (check all that apply)

1a.1.

 WBC

2a.1.

 WBC

3a.1.

 WBC

4a.1.

 WBC

1a.2.

 Protein

2a.2.

 Protein

3a.2.

 Protein

4a.2.

 Protein

1a.3.

 Glucose

2a.3.

 Glucose

3a.3.

 Glucose

4a.3.

 Glucose

1a.4.

 Gram stain

2a.4.

 Gram stain

3a.4.

 Gram stain

4a.4.

 Gram stain

1a.5.

Other (specify): ____________1a.5.sp.

2a.5.

Other (specify): ____________2a.5.sp.

3a.5.

Other (specify): ____________3a.5.sp.

4a.5.

Other (specify): ____________4a.5.sp.

1a.6.

NR

2a.6.

NR

3a.6.

NR

4a.6.

NR

1a.7.

IL

2a.7.

IL

3a.7.

IL

4a.7.

IL

N. Temperature No information for any item in section Test/procedure for one or more items in section indicated but no information on dates, results, etc.
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.	1a. __ __/__ __/__ __ __ __	1b. ______ 1b.1. 1 Once 2 Hours 3 Days 88 IL 99 NR	1c. _______ 1c.1. Units: 1 oC 2 oF 88 IL 99 NR	1d. 1 Axillary 2 Rectal 3 Oral 4 Skin 88 IL 99 NR	1e. 1 Warmer 2 Isolette 88 IL 99 NR	1f. 1 Bundled 2 Moved to warmer 3 Moved to isolette 4 Other (specify) _____________1f.sp. 88 IL 99 NR	1g. 1 Yes 2 No 88 IL 99 NR
2.	2a. __ __/__ __/__ __ __ __	2b. ______ 2b.1. 1 Once 2 Hours 3 Days 88 IL 99 NR	2c. _______ 2c.1. Units: 1 oC 2 oF 88 IL 99 NR	2d. 1 Axillary 2 Rectal 3 Oral 4 Skin 88 IL 99 NR	2e. 1 Warmer 2 Isolette 88 IL 99 NR	2f. 1 Bundled 2 Moved to warmer 3 Moved to isolette 4 Other (specify) _____________2f.sp. 88 IL 99 NR	2g. 1 Yes 2 No 88 IL 99 NR
3.	3a. __ __/__ __/__ __ __ __	3b. ______ 3b.1. 1 Once 2 Hours 3 Days 88 IL 99 NR	3c. _______ 3c.1. Units: 1 oC 2 oF 88 IL 99 NR	3d. 1 Axillary 2 Rectal 3 Oral 4 Skin 88 IL 99 NR	3e. 1 Warmer 2 Isolette 88 IL 99 NR	3f. 1 Bundled 2 Moved to warmer 3 Moved to isolette 4 Other (specify) _____________3f.sp. 88 IL 99 NR	3g. 1 Yes 2 No 88 IL 99 NR
4. Comments:

O. SURGICAL HISTORY No information for any item in section
* 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. Note: If infection occurred complete Section K.
1. Circumcision 1 Yes 2 No 77 NA(female) 88 IL 99 NR			1b. Anesthesia* 1 Conscious Sedation 2 Local 3 Epidural 4 General 5 None 88 IL 99 NR	1c. Medications Given* 1Yes 2 No 88 IL 99 NR
1a. Date __ __/__ __/__ __ __ __				1d. Temperature** 1Yes 2 No 88 IL 99 NR
1e. Complications and Comments (e.g. type of injury), (Specify) _________________________________________________________________________________________________1e.sp.
2. Proc 1	2a. CPT Code ________ 9 Unknown	2b. Date __ __/__ __/__ __ __ __ 9 Unknown	2d. Anesthesia* 1 Conscious Sedation 2 Local 3 Epidural 4 General 5 None 88 IL 99 NR	2e. Medications Given* 1Yes 2 No 88 IL 99 NR
	2c. Name of Procedure (Specify) _________________________________ 2c.sp.			2f. Temperature** 1Yes 2 No 88 IL 99 NR
2g. Complications and Comments (e.g. type of injury), (Specify) _________________________________________________________________________________________________2g.sp.
3. Proc 2	3a. CPT Code _________ 9 Unknown	3b. Date __ __/__ __/__ __ __ __ 9 Unknown	3d. Anesthesia* 1 Conscious Sedation 2 Local 3 Epidural 4 General 5 None 88 IL 99 NR	3e. Medications Given* 1Yes 2 No 88 IL 99 NR
	3c. Name of Procedure (Specify) _________________________________ 3c.sp.			3f. Temperature** 1Yes 2 No 88 IL 99 NR
3g. Complications and Comments (e.g. type of injury), (Specify) _________________________________________________________________________________________________3g.sp.
4. Proc 3	4a. CPT Code _________ 9 Unknown	4b. Date __ __/__ __/__ __ __ __ 9 Unknown	4d. Anesthesia* 1 Conscious Sedation 2 Local 3 Epidural 4 General 5 None 88 IL 99 NR	4e. Medications Given* 1Yes 2 No 88 IL 99 NR
	4c. Name of Procedure (Specify) _________________________________4c.sp.			4f. Temperature** 1Yes 2 No 88 IL 99 NR
4g. Complications and Comments (e.g. type of injury), (Specify) _________________________________________________________________________________________________4g.sp.

P. MEDICATIONS No information for any item in section
REF: Indicate the letter and number of the event from the previous section (e.g. J2 – for Section J, #2), otherwise enter the reason from the 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/psychotropics, 20 = antihypertensives/diuretics, 21 = cardiovascular, 22 = narcotic antagonists, 23 = ergotrate, 24 =antidepressants, 25 = vitamins, 26 = asthma/respiratory stimulant, 27 = preterm labor prevention, 28 = neonatal resuscitation, 29 = dextrose, 30 = antipyretics, 31 = hematologic, 32 = gastrointestinal, 33 =anti-neoplastic, 88 = other (specify), 888 = illegible, 999 = not recorded Reason: Specify
	REF	Code	Drug Name	Reason	Start Date	Stop Date	Dose	Unit	Frequency
1	1a. _______	1b.	1c.	1d.	1e. _ _ /_ _ /_ _ _ _	1f. _ _ /_ _ /_ _ _ _ 1 Ongoing	1g. __________ 8 Variable* *End Dose: (specify) ______1g.sp.	1h. 1 gm 2 mg 3 mcg 4 mU 5 cc/ml 8 other 88 IL 99 NR	1i. 1 QD 2 BID 3 TID 4 QID 5 PRN 6. Every ___ hrs 7 Per week 8 Total Dose 88 IL 99 NR
2	2a. _______	2b.	2c.	2d.	2e. _ _ /_ _ /_ _ _ _	2f. _ _ /_ _ /_ _ _ _ 1 Ongoing	2g. __________ 8 Variable* *End Dose: (specify) ______2g.sp.	2h. 1 gm 2 mg 3 mcg 4 mU 5 cc/ml 8 other 88 IL 99 NR	2i. 1 QD 2 BID 3 TID 4 QID 5 PRN 6. Every ___ hrs 7 Per week 8 Total Dose 88 IL 99 NR
3	3a. _______	3b.	3c.	3d.	3e. _ _ /_ _ /_ _ _ _	3f. _ _ /_ _ /_ _ _ _ 1 Ongoing	3g. __________ 8 Variable* *End Dose: (specify) ______3g.sp.	3h. 1 gm 2 mg 3 mcg 4 mU 5 cc/ml 8 other 88 IL 99 NR	3i. 1 QD 2 BID 3 TID 4 QID 5 PRN 6. Every ___ hrs 7 Per week 8 Total Dose 88 IL 99 NR
4	4a. _______	4b.	4c.	4d.	4e. _ /_ _ /_ _ _ _	4f. _ _ /_ _ /_ _ _ _ 1 Ongoing	4g. __________ 8 Variable* *End Dose: (specify) ______4g.sp.	4h. 1 gm 2 mg 3 mcg 4 mU 5 cc/ml 8 other 88 IL 99 NR	4i. 1 QD 2 BID 3 TID 4 QID 5 PRN 6 Every ___ hrs 7 Per week 8 Total Dose 88 IL 99 NR
5	5a. _______	5b.	5c.	5d.	5e. _ _ /_ _ /_ _ _ _	5f. _ _ /_ _ /_ _ _ _ 1 Ongoing	5g. __________ 8 Variable* *End Dose: (specify) ______5g.sp	5h. 1 gm 2 mg 3 mcg 4 mU 5 cc/ml 8 other 88 IL 99 NR	5i. 1 QD 2 BID 3 TID 4 QID 5 PRN 6 Every ___ hrs 7 Per week 8 Total Dose 88 IL 99 NR
6. Comments

Q. Blood product transfusions No information for any item in section Test/procedure for one or more items in section indicated but no information on dates, results, etc.
Exclude normal saline partial exchange transfusion for polycythemia and albumin infusions for hypotension
Total # 1 None 2 One 3 More than one 88 IL 99 NR
2. Reasons for transfusions (check all that apply)
2a. 	Iatrogenic anemia	2b. 	Thrombocytopenia	2c. 	Hyperbilirubinemia
2d. 	Anemia of prematurity	2e. 	DIC	2f. 	Other (specify) ______________________2f.sp.
2g. 	Other anemia (specify): ______________________2g.sp.	2h. 	Other clotting factor deficiency (specify): _____________________2h.sp.	2i. 	Other (specify): ______________________2i.sp.
3. Comments:

R. NEUROLOGY CONSULTS No information for any item in section
Neurology Codes: 1 = Birth asphyxia 2 = Brachial plexus injury 3 = Seizures 4 = Metabolic disorders 8 = Other (specify) 88 = IL 99 = NR
REF.: 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.	1a. Date: __ __/__ __/__ __ __ __	1b. REF or Reason _______________1b.sp. 88 IL 99 NR	1c. Neurology Code	1d. Medication Given* 1 Yes 2 No 88 IL 99 NR	1e. Comments
2.	2a. Date: __ __/__ __/__ __ __ __	2b. REF or Reason _______________2b.sp. 88 IL 99 NR	2c. Neurology Code	2d. Medication Given* 1 Yes 2 No 88 IL 99 NR	2e. Comments
3.	3a. Date: __ __/__ __/__ __ __ __	3b. REF or Reason _______________3b.sp. 88 IL 99 NR	3c. Neurology Code	3d. Medication Given* 1 Yes 2 No 88 IL 99 NR	3e. Comments
4.	4a. Date: __ __/__ __/__ __ __ __	4b. REF or Reason _______________4b.sp. 88 IL 99 NR	4c. Neurology Code	4d. Medication Given* 1 Yes 2 No 88 IL 99 NR	4e. Comments

S. SEIZURES No information for any item in section
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), 888 = Ilegible, 99 = Not Recorded
1. Date __ __/__ __/__ __ __ ___	1a. Time ____ : ____	1b. Describe episode (check all that apply)	1c. Witnessed by (check all that apply)
		1b.1. 1 Clonic/convulsive 1b.2. 2 Tonic/posturing 1b.3. 3 Myoclonic 1b.4. 4 Subtle 1b.5. 8 Other (specify): __________________1b.5.sp. 1b.6. 88 IL 1b.7. 99 NR	1c.1. 1 MD 1c.2. 2 RN 1c.3. 3 Parent 1c.4. 8 Other (specify) _______________1c.4.sp. 1c.5. 88 IL 1c.6. 99 NR
1d. Proximate cause1 ________________________1d.sp.		1e. Proximate cause2 ________________________1e.sp.
1f. Meds given in response to seizure (specify in Section P) 1 Yes 2 No 88 IL 99 NR		1g. Comments:
2. Date __ __/__ __/__ __ __ ___	2a. Time ____ : ____	2b. Describe episode (check all that apply)	2c. Witnessed by (check all that apply)
		1b.1. 1 Clonic/convulsive 1b.2. 2 Tonic/posturing 1b.3. 3 Myoclonic 1b.4. 4 Subtle 1b.5. 8 Other (specify): __________________1b.5.sp. 1b.6. 88 IL 1b.7. 99 NR	1c.1. 1 MD 1c.2. 2 RN 1c.3. 3 Parent 1c.4. 8 Other (specify) _______________1c.4.sp. 1c.5. 88 IL 1c.6. 99 NR
2d. Proximate cause1 ________________________2d.sp.		2e. Proximate cause2 ________________________2e.sp.
2f. Meds given in response to seizure (specify in Section P) 1 Yes 2 No 88 IL 99 NR		2g. Comments:
3. Date __ __/__ __/__ __ __ ___	3a. Time ____ : ____	3b. Describe episode (check all that apply)	3c. Witnessed by (check all that apply)
		1b.1. 1 Clonic/convulsive 1b.2. 2 Tonic/posturing 1b.3. 3 Myoclonic 1b.4. 4 Subtle 1b.5. 8 Other (specify): __________________1b.5.sp. 1b.6. 88 IL 1b.7. 99 NR	1c.1. 1 MD 1c.2. 2 RN 1c.3. 3 Parent 1c.4. 8 Other (specify) _______________1c.4.sp. 1c.5. 88 IL 1c.6. 99 NR
3d. Proximate cause1 ________________________3d.sp.		3e. Proximate cause2 ________________________3e.sp.
3f. Meds given in response to seizure (specify in Section P) 1 Yes 2 No 88 IL 99 NR		3g. Comments:

T. Cranial Ultrasounds No information for any item in section Test/procedure for one or more items in section indicated but no information on dates, results, etc.
Please abstract all ultrasounds, unless the findings are clearly the same.
1. Date __ __/__ __/__ __ __ __			1a. Results 1 Normal 2 Abnormal 3 Equivocal 88 IL 99 NR	Hemisphere (H): 1=Right, 2=Left, 3=Bilateral, 88=Illegible, 99=Not Recorded Location (L): 1=Anterior/Frontal, 2=Posterior/Occipital, 3=Parietal, 4=Temporal, 88=Illegible, 99=Not Recorded Size (S): 1=Small/Mild, 2=Medium/Moderate, 3=Large/Severe, 88=Illegible, 99=Not Recorded
Findings: 1 = No, 2 = Definite, 3= Suspect, 77 = NA, 88 = IL, 99 = NR				H	L	S	Description/Comments
1b.	Ventriculomegaly			1b.1.	1b.2.	1b.3.	1b.4.
1c.	Echodensity/echogenicity			1c.1.	1c.2.	1c.3.	1c.4.
1d.	Echolucency			1d.1.	1d.2.	1d.3.	1d.4.
1e.	IVH grade (e.g. l I-IV) ____________			1e.1.	1e.2.	1e.3.	1e.4.
1f.	Germinal matrix bleed (Grade I IVH)			1f.1.	1f.2.	1f.3.	1f.4.
1g.	Other bleed			1g.1.	1g.2.	1g.3.	1g.4.
1h.	PVL/cavitation/white matter necrosis			1h.1.	1h.2.	1h.3.	1h.4.
1i.	Malformation			1i.1.	1i.2.	1i.3.	1i.4.
1j.	Subarachnoid hemorrhage/blood			1j.1.	1j.2.	1j.3.	1j.4.
1k.	Other findings, (specify) _______________________________________1k.sp.			1k.1.	1k.2.	1k.3.	1k.4.
2. Date __ __/__ __/__ __ __ __		2a. Results 1 Normal 2 Abnormal 3 Equivocal 88 IL 99 NR		Hemisphere (H): 1=Right, 2=Left, 3=Bilateral, 88=Illegible, 99=Not Recorded Location (L): 1=Anterior/Frontal, 2=Posterior/Occipital, 3=Parietal, 4=Temporal, 88=Illegible, 99=Not Recorded Size (S): 1=Small/Mild, 2=Medium/Moderate, 3=Large/Severe, 88=Illegible, 99=Not Recorded
Findings: 1 = No, 2 = Definite, 3 = Suspect, 77 = NA, 88 = IL, 99 = NR				H	L	S	Description/Comments
2b.	Ventriculomegaly			2b.1.	2b.2.	2b.3.	2b.4.
2c.	Echodensity/echogenicity			2c.1.	2c.2.	2c.3.	2c.4.
2d.	Echolucency			2d.1.	2d.2.	2d.3.	2d.4.
2e.	IVH grade (e.g. l I-IV) ____________			2e.1.	2e.2.	2e.3.	2e.4.
2f.	Germinal matrix bleed (Grade I IVH)			2f.1.	2f.2.	2f.3.	2f.4.
2g.	Other bleed			2g.1.	2g.2.	2g.3.	2g.4.
2h.	PVL/cavitation/white matter necrosis			2h.1.	2h.2.	2h.3.	2h.4.
2i.	Malformation			2i.1.	2i.2.	2i.3.	2i.4.
2j.	Subarachnoid hemorrhage/blood			2j.1.	2j.2.	2j.3.	2j.4.
2k.	Other findings, (specify) _______________________________________2k.sp.			2k.1.	2k.2.	2k.3.	2k.4.

U. cranial studies (EEG, MRI and CT Scan) No information for any item in section Test/procedure for one or more items in section indicated but no information on dates, results, etc.
Please abstract all tests, unless the findings are clearly the same. Code: 1 = EEG, 2 = Cranial MRI, 3 = CT scan, 8 = Other (specify in comments), 88 = Illegible, 99 = Not Recorded
1. Date __ __/__ __/__ __ __ ___	1a. Code	1b. Results 1 Normal 2 Abnormal 3 Equivocal 88 IL 99 NR	1c. Final Impression (specify) _____________________________1c.sp.	1d. Comments
2. Date __ __/__ __/__ __ __ ___	2a. Code	2b. Results 1 Normal 2 Abnormal 3 Equivocal 88 IL 99 NR	2c. Final Impression (specify) _____________________________2c.sp.	2d. Comments
3. Date __ __/__ __/__ __ __ ___	3a. Code	3b. Results 1 Normal 2 Abnormal 3 Equivocal 88 IL 99 NR	3c. Final Impression (specify) _____________________________3c.sp.	3d. Comments
4. Date __ __/__ __/__ __ __ ___	4a. Code	4b. Results 1 Normal 2 Abnormal 3 Equivocal 88 IL 99 NR	4c. Final Impression (specify) _____________________________1c.sp.	4d. Comments
5. Date __ __/__ __/__ __ __ ___	5a. Code	5b. Results 1 Normal 2 Abnormal 3 Equivocal 88 IL 99 NR	5c. Final Impression (specify) _____________________________2c.sp.	5d. Comments
6. Date __ __/__ __/__ __ __ ___	6a. Code	6b. Results 1 Normal 2 Abnormal 3 Equivocal 88 IL 99 NR	6c. Final Impression (specify) _____________________________3c.sp.	6d. Comments

V. OTHER Procedure or study (ECG, Chest X-ray, Genetic Study, lab test, etc.) No information for any item in section Test/procedure for one or more items in section indicated but no information on dates, results, etc.
	REF/Reason	Type of Procedure	Date	Outcome
1.	1a.	1b.	1c. _ _/_ _/_ _ _ _	1d.
2.	2a.	2b.	2c. _ _/_ _/_ _ _ _	2d.
3.	3a.	3b.	3c. _ _/_ _/_ _ _ _	3d.
4.	4a.	4b.	4c. _ _/_ _/_ _ _ _	4d.
5.	5a.	5b.	5c. _ _/_ _/_ _ _ _	5d.
6.	6a.	6b.	6c. _ _/_ _/_ _ _ _	6d.
7.	7a.	7b.	7c. _ _/_ _/_ _ _ _	7d.
8.	8a.	8b.	8c. _ _/_ _/_ _ _ _	8d.
9.	9a.	9b.	9c. _ _/_ _/_ _ _ _	9d.
10.	10a.	10b.	10c. _ _/_ _/_ _ _ _	10d.
11.	11a.	11b.	11c. _ _/_ _/_ _ _ _	11d.
12.	12a.	12b.	12c. _ _/_ _/_ _ _ _	12d.
13.	13a.	13b.	13c. _ _/_ _/_ _ _ _	13d.
14.	14a.	14b.	14c. _ _/_ _/_ _ _ _	14d.
15. Comments:

W. Disposition at Final discharge No information for any item in section Test/procedure for one or more items in section indicated but no information on dates, results, etc.
1. Date of DC __ __/__ __/__ __ __ ___		2. Head Circumference ______________ 1 in 2 cm 88 IL 99 NR			3. Height/Length ______________ 1 in 2 cm 88 IL 99 NR		4. Weight ______________ 1 Lbs 2 Kg 88 IL 99 NR		5. Discharged to: 1 Home with biological parent(s) 2 Foster care 3 Adopted 4 Custodial care 8 Other (specify) _______________________5.sp. 88 IL 99 NR
Medications at Discharge 1 Yes (Fill out Section P) 88 IL 2 No 99 NR
7. Documented Referrals (check all that apply) No information for any item in section
7a. 	Routine pediatrician appointment		7d. 	Home health nurse home visit(s)				7g. 		Ophthalmology follow-up
7b. 	Audiology follow-up		7e. 	High-risk infant follow-up clinic				7h. 		Public health home visit(s)
7c. 	Nutritional support 1 Breast 2 Formula 3 Combination 4 Tube 8 Other (specify) _________________7c.sp. 88 IL 99 NR		7f. 	Respiratory support 1 Oxygen 2 Respiratory support 3 Apnea monitor 8 Other (specify) _________________________7f.sp. 88 IL 99 NR				7i. 		Home therapies (specify) _____________________7i.sp.
								7j. 		Other (specify) _____________________7j.sp.
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 88 IL 99 NR

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