Part A Attachment C Electronic Health Records Elements

Part A Attachment C Electronic Health Records Elements.docx

Evaluation of the Text4baby Program

Part A Attachment C Electronic Health Records Elements

OMB: 0915-0347

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ATTAChment C

electronic health records data elements








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Table C.1 Measures and Data Elements to be Obtained from Electronic Health Records, by Domain

Measures

Data Elements for Abstraction

Unique Identifiers

Woman’s unique ID

Woman’s medical record number (or other unique ID)

Infant’s unique ID

Infant’s medical record number (or other unique ID)

Unique ID to link woman and infant

Unique ID to link woman and infant (if available)

Demographic Measures

Woman’s age at delivery


Woman’s date of birth (Month, Day, Year);

Woman’s date of delivery (Month, Day, Year)

Woman’s race/ethnicity

Race; ethnicity

Woman’s primary language

Primary language (English/Spanish/Other)

Woman’s insurance source

Insurance source (Medicaid/Private/Uninsured)

Infant’s date of birth

Infant’s date of birth (Month, Day, Year)

Infant’s sex

Infant’s sex (M/F)

Clinical Risk Profile Measures

Multiple gestations

Multiple gestations (Y/N; if yes, number)

Pregnancy history

Number of previous pregnancies; number of previous live births; previous infant death in first year of life (Y/N)

Woman’s body mass index (BMI) at beginning of pregnancy

Woman’s height at beginning of pregnancy; woman’s weight at beginning of pregnancy

Major pre-existing conditions/diagnoses


Preexisting conditions diagnoses (Y/N for each): hypertension, diabetes, asthma, other cardiovascular, obesity, smoking, depression,

Major pregnancy complications/diagnoses


Specified pregnancy complications (Y/N for each): Gestational diabetes; Pregnancy-induced hypertension; Preeclampsia; Intrauterine growth retardation; anemia; Ectopic pregnancy; Hyperemesis gravidarum; Placenta previa; Placental abruption; Preterm labor; Preterm birth; Premature ruptured membranes

Prenatal Utilization Measures

Adequacy of prenatal care

Dates of prenatal care visits (to calculate number per trimester, first visit month, and total number of visits); EDOC/LMP; date of delivery

Receipt of dental care

Date of last dental visit

Number of physician visits during pregnancy

Total number of visits for primary care or specialty care during pregnancy

Specialty care referrals/visits during pregnancy

Specialty care referral/visit (Y/N for each): allergy/immunology, anesthesiology, cardiology, psychiatry/behavioral health/addiction medicine, dermatology, ear/nose/throat, endocrinology/diabetes/metabolism, general surgery, gastroenterology, hematology, medical oncology, infectious disease, neonatal/perinatal medicine, genetics, nephrology, neurology, pulmonary medicine, diagnostic radiology, rheumatology, urology, vascular surgery, physical therapy, reconstructive surgery

Smoking cessation class

Attended smoking cessation class (Y/N)

Seasonal flu shot

Date of influenza immunization

Prenatal class attendance

Attended prenatal class (Y/N)

Nutritional counseling

Received nutritional counseling (Y/N)

Indicator of breastfeeding plan

Plan to breastfeed reported in prenatal record (Y/N)


Table C.1 (continued)

Measures

Data Elements for Abstraction

Pregnancy Outcome Measures

Pregnancy outcome

Pregnancy outcome (Y/N): Delivered live birth; Delivered stillborn; Elective termination; Miscarriage

Major procedures performed during delivery


Procedures performed during delivery (Y/N for each): Induced labor; Caesarian section; repair of current obstetric laceration; artificial rupture of membranes to assist delivery; forceps or other assisted delivery; episiotomy; intra-partum fetal monitoring

Premature (<37 weeks) or very premature (<34 weeks) delivery

Expected date of delivery (EDD), actual date of delivery

Low (<2500 grams) or very low (<1500 grams) birth weight

Infant’s birth weight

Weight gain during pregnancy

Woman’s weight at beginning of pregnancy and at last prenatal visit

Postpartum Utilization Measures: Woman

Woman’s postpartum check-up within six weeks

Date of delivery (month/day/year), postpartum visit date (month/day/year)

Number of physician visits during nine months postpartum period

Total number of visits for primary care or specialty care during nine months postpartum

Specialty care visits during nine months postpartum

Specialty care visit (Y/N): allergy/immunology, anesthesiology, cardiology, psychiatry/behavioral health/addiction medicine, dermatology, ear/nose/throat, endocrinology/diabetes/metabolism, general surgery, gastroenterology, hematology, medical oncology, infectious disease, neonatal/perinatal medicine, nephrology, neurology, obstetrics/gynecology, pulmonary medicine, diagnostic radiology, rheumatology, urology, vascular surgery, physical therapy, reconstructive surgery

Indicator of birth control plan at postpartum check-up

Birth control method noted (Y/N): none, condom, tubal ligation, IUD, pill, patch, ring, DepoProvera shot, Implanon implant, other (specify)

Subsequent pregnancy within nine months postpartum

Subsequent pregnancy within nine months (Y/N); estimated delivery date

Postpartum Utilization Measures: Infant

Number of infant visits during first nine months

Total number of visits for primary care or specialty care during infant’s first nine months of life

Pediatric specialty care referrals/visits during first nine months of life

Specialty care referral/visit (Y/N for each):allergy/immunology, anesthesiology, cardiology, psychiatry/behavioral health/addiction medicine, dermatology, ear/nose/throat, endocrinology/diabetes/metabolism, general surgery, gastroenterology, hematology, medical oncology, infectious disease, neonatal/perinatal medicine, nephrology, neurology, pulmonary medicine, diagnostic radiology, rheumatology, urology, vascular surgery, physical therapy, reconstructive surgery

Compliance with schedule for well-baby visits (number, periodicity)

Dates of all well-baby visits (Month/Day/Year) to calculate first visit and number of total visits in relation to infant’s date of birth

Breastfeeding status

Breastfeeding (Y/N for each): at hospital discharge, at 1 month well-baby visit, at 3 month well-baby visit

Compliance with infant immunization schedule

Vaccinations received (Month/Day/Year): Hepatitis B; Rotavirus; Diphtheria, Tetanus, Pertussis; Haemophilus influenzae type b; Pneumococcal; Inactivated Poliovirus; Influenza; Measles, Mumps, Rubella; Varicella; Hepatitis A



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