Electronic Health Records Elements

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