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pdfStudy ID: __ __ __ __ __ __
Date completed (MM‐DD‐YY): __ __ / __ __ / __ __
Name of Abstracter: ________________________________
□
Prenatal Clinic:
Chinle
□
Gallup
□
Shiprock
□
Ft. Defiance
□
Tuba City
□
Other (Specify) ____________
PRENATAL AND PREGNANCY MEDICAL RECORD ABSTRACTION FORM
PREGNANCY HISTORY
Grav
___ ___
Para
Term ___ ___
___ ___
Premature ___ ___
Abs ___ ___ Living ___ ___ Stillbirth ___ ___
Neonatal death ___ ___
Previous Pregnancies (Provide details for all live‐born children):
1) Date of Birth __ __ / __ __ / __ __ Weeks Gestation ___ ___
□ □
□ □
Type of Delivery
Vaginal
Infant
Male
Sex
Infant
Male
Sex
Infant
Male
Sex
Infant
Male
Sex
Multiple (Number___)
□
Emergency Cesarean
Female [If more than one, place number in box for each infant sex]
□
□
Singleton
□
Vaginal‐assisted
Multiple (Number___)
□
Scheduled Cesarean
Emergency Cesarean
Female [If more than one, place number in box for each infant sex]
□ □
□ □
Vaginal
□
Singleton
Scheduled Cesarean
4) Date of Birth __ __ / __ __ / __ __ Weeks Gestation ___ ___
Type of Delivery
Emergency Cesarean
□
□
Vaginal‐assisted
□ □
□ □
Vaginal
□
Scheduled Cesarean
3) Date of Birth __ __ / __ __ / __ __ Weeks Gestation ___ ___
Type of Delivery
Multiple (Number___)
Female [If more than one, place number in box for each infant sex]
□ □
□ □
Vaginal
□
Singleton
□
Vaginal‐assisted
2) Date of Birth __ __ / __ __ / __ __ Weeks Gestation ___ ___
Type of Delivery
□
□
Vaginal‐assisted
□
□
Singleton
Multiple (Number___)
□
Scheduled Cesarean
Emergency Cesarean
Female [If more than one, place number in box for each infant sex]
5) Date of Birth __ __ / __ __ / __ __ Weeks Gestation ___ ___
□ □
□ □
Type of Delivery
Vaginal
Infant
Male
Sex
□ □
□ □
Vaginal
Infant
Male
□
□
Singleton
□
Vaginal‐assisted
Multiple (Number___)
□
Scheduled Cesarean
□ □
□ □
Vaginal
Emergency Cesarean
Infant
Male
□
□
Singleton
□
Vaginal‐assisted
Multiple (Number___)
□
Scheduled Cesarean
Emergency Cesarean
Female [If more than one, place number in box for each infant sex]
8) Date of Birth __ __ / __ __ / __ __ Weeks Gestation ___ ___
□ □
□ □
Type of Delivery
Vaginal
Infant
Male
□
□
Singleton
□
Vaginal‐assisted
Multiple (Number___)
□
Scheduled Cesarean
Emergency Cesarean
Female [If more than one, place number in box for each infant sex]
9) Date of Birth __ __ / __ __ / __ __ Weeks Gestation ___ ___
□ □
□ □
Type of Delivery
Vaginal
Infant
Male
□
Vaginal‐assisted
□
□
Singleton
Multiple (Number___)
□
Scheduled Cesarean
Emergency Cesarean
Female [If more than one, place number in box for each infant sex]
□
Check this box if more than 9 (nine) live‐born children
Emergency Cesarean
Female [If more than one, place number in box for each infant sex]
Type of Delivery
Sex
□
Scheduled Cesarean
7) Date of Birth __ __ / __ __ / __ __ Weeks Gestation ___ ___
Sex
Multiple (Number___)
Female [If more than one, place number in box for each infant sex]
Type of Delivery
Sex
□
Singleton
□
Vaginal‐assisted
6) Date of Birth __ __ / __ __ / __ __ Weeks Gestation ___ ___
Sex
□
PRENATAL RISK ASSESSMENT
Reproductive History:
Age Under 16 or Over 35
Parity 0 or Over 5
Habitual Abortion
Infertility
P P Hem, Manual Removal
Previous baby >9lbs (4050 gms)
<5 ½ lbs (2500 gms)
Previous Toxemia, Hypertension
Previous Cesarean Section
Previous Stillbirth or N N D
Prolonged Labor (>30 Hrs.) or
Difficult Delivery
Other__________________
Other__________________
Associated Conditions:
Chronic Renal Disease
Diabetes: Gestational
Class B or Higher
Cardiac Disease
Major Gyn Surgery, Cone Bx
Other_________________
Other_________________
Other_________________
Cigarette Smoking
Alcohol Use
Teratogen/Drug Exposure
____________________
Significant Social Problem
_____________________
Present Pregnancy:
Bleeding Less than 20 wks
Bleeding After 20 wks
Anemia: Hematocrit <34
Prolonged Pregnancy >42 wks
Hypertension, Preeclampsia
Premature Rupture Membranes
Polyhydramnios
Small for Dates
Multiple Pregnancy
Breech > 36 weeks
Rh Negative, Sensitized?
Genital Herpes, active
Excessive or inadequate wt. gain
Other__________________
TOTAL RISK SCORE
____ (1)
____ (1)
____ (1)
____ (1)
____ (1)
____ (1)
____ (2)
____ (1)
____ (3)
____ (3)
____ (1)
____ (1)
____ (1)
____ (2)
____ (2)
____ (3)
____ (1‐3)
____ (2)
____ (1‐3)
____ (1‐3)
____ (1‐3)
____ (1)
____ (1‐2)
____ (1‐2)
____ (1‐3)
____ (1)
____ (1‐3)
____ (1)
____ (3)
____ (2‐3)
____ (3)
____ (2)
____ (3)
____ (3)
____ (3)
____ (1‐3)
____ (3)
____ (1‐2)
____ (1‐3)
□□
CURRENT PREGNANCY
Gestational Assessments:
Menstrual History
LNMP __ __ / __ __ / __ __
□ □ □
□
Use of BCPs
Yes
No
Don’t know
Yes
No
If yes, last date taken __ __ / __ __ / __ __
□
Planned
Attitude Towards Pregnancy:
□ □ □
□
Certainty of Date
Don’t know
Don’t know
□
Unplanned
Don’t know
Clinical Evaluation:
Is there evidence of a positive pregnancy test (hCG)?
Pregnancy Test Date __ __ / __ __ / __ __
□ □ □
Yes
No
Don’t know
First uterine size estimate by bimanual examination __ __ / __ __ / __ __ Gestational Age __ __ weeks
□ □ □
□
Poor
Good
Excellent
Don’t know
Predicted EDC __ __ / __ __ / __ __
Reliability of Estimate:
First Ultrasound Date __ __ / __ __ / __ __
Gestational Age __ __ weeks Sonar EDC __ __ / __ __ / __ __
Last Ultrasound Date __ __ / __ __ / __ __
Gestational Age __ __ weeks Sonar EDC __ __ / __ __ / __ __
□
□
Number of fetuses
Singleton
Multiple If Multiple fetuses, how many? ___ ___
Fetal heart tones first heard by Doppler
Date: __ __ / __ __ / __ __
Fetal heart tones first heard by fetoscope
Date: __ __ / __ __ / __ __
Fetal movement first perceived by patient (quickening) Date: __ __ / __ __ / __ __
Prenatal Visit History:
□
Total Number of Prenatal Visits ___ ___ [Check box if unknown
]
□
First Prenatal Visit Date __ __ / __ __ / __ __ [Check box if unknown
]
Pre‐pregnancy weight _____ _____ _____ lb, _____ _____ oz. or
_____ _____. _____ kg
Term pregnancy weight _____ _____ _____ lb, _____ _____ oz. or
_____ _____. _____ kg
Was RHO (D) immune globulin (Gamulin Rh, HypRho‐D, Rhesonativ, RhoGAM) given to the patient during this
pregnancy?
□ □ □
Yes
No
Don’t know
If yes, date: __ __ / __ __ / __ __
Behavioral Assessment:
□ □ □
Smoking Tobacco Cigarettes during pregnancy
Yes
No
Number of Cigarettes per day during pregnancy ___ ___
Don’t know
□ □ □
Smoking Tobacco Cigarettes before pregnancy
Yes
No
Number of Cigarettes per day before pregnancy ___ ___
Don’t know
□ □ □
Alcohol use during pregnancy
Yes
No
Don’t know
Number of Alcoholic drinks per week during pregnancy ___ ___
□ □ □
Alcohol use before pregnancy
Yes
No
Don’t know
Number of Alcoholic drinks per week before pregnancy ___ ___
□ □ □
Yes
No
Don’t know
Ceremonial drug use during pregnancy (e.g. peyote)
If yes, specify type ______________________________________________________________
□ □ □
Yes
No
Don’t know
Prescription drug use during pregnancy
If yes, specify type ______________________________________________________________
□ □ □
Illicit drug use during pregnancy
Yes
No
Don’t know
If yes, specify type ______________________________________________________________
□ □ □
Yes
No
Don’t know
Prenatal vitamin use during pregnancy
If yes, specify brand/type_________________________________________________________
Estimated start of use ____ _____ (weeks of gestation)
Estimated compliance:
□ □ □
Poor
Good
□
Excellent
Don’t know
Referrals/Counseling:
Did the patient receive any of the following types of referrals or counseling during her prenatal care?
□
□
□
□
□
□
□
□
□
□
□
□
Diabetic diet
Alcohol abuse
Drug abuse
Smoking cessation
Other (specify:_________________________)
Yes
No
Don’t know
Yes
No
Don’t know
Yes
No
Don’t know
Yes
No
Don’t know
□ □ □
Yes
No
Don’t know
PRENATAL FLOW RECORD
Summary of Prenatal Visits
Date
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Weight (lbs)
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Systolic
BP
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Diastolic
BP
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Urine
protein
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Condition of Cervix / Station / Fetal Presentation
(During last two months of prenatal care)
Dilation
Effacement
Date
(cm)
(%)
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Station
(‐3 to +3)
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Fetal
presentation
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Urine
glucose
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Fundal
height
(cm)
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Estimated
gest. age
(weeks)
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ROUTINE LABORATORY TEST RESULTS (First Prenatal Visit ‐or‐ First Available)
GC
□ □ □
□ □ □
□ □ □
Chlamydia
B Strep
Pos
Neg
Don’t know/missing
Date __ __ / __ __ / __ __
Pos
Neg
Don’t know/missing
Date __ __ / __ __ / __ __
Pos
Neg
Don’t know/missing
Date __ __ / __ __ / __ __
Creatinine clearance (mL/min) __ __ __
Date __ __ / __ __ / __ __
Urine 24 hours protein (mg/24 hour) __ __ __
Date __ __ / __ __ / __ __
Hgb (g/dL)
__ __ . __
Date __ __ / __ __ / __ __
Hct (%)
__ __
Date __ __ / __ __ / __ __
MCV (fL)
__ __ __
Date __ __ / __ __ / __ __
RDW (%)
__ __
Date __ __ / __ __ / __ __
Date __ __ / __ __ / __ __
Date __ __ / __ __ / __ __
Folate (ng/ml) __ __ . __
E3
__ __ . __
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High
Normal/Neg
Low
Immune
Not Immune
Don’t know/missing
Serum AFP
Rubella
Hepatitis B (HBsAg)
Syphillis
Positive
□
Positive
Negative
Negative
□ □ □
Pos
Neg
Date __ __ / __ __ / __ __
Don’t know/missing Date __ __ / __ __ / __ __
Don’t know/missing
VDRL (quantitative) ___ ___ ___
Urine C&S
Don’t know/missing Date __ __ / __ __ / __ __
Date __ __ / __ __ / __ __
Date __ __ / __ __ / __ __
Don’t know/missing
Date __ __ / __ __ / __ __
□ □ □
Was patient ever treated for urinary tract infection (UTI) in current pregnancy?
If yes, how was patient treated? (specify)_____________________________
Yes
No
Don’t know
Date __ __ / __ __ / __ __
OTHER TESTING
□ □ □
Did the patient have an amniocentesis during the current pregnancy?
Yes
No
□
Refused
Don’t know
If yes, date: __ __ / __ __ / __ __
□ □
□ □
Normal
Chromosomal type
Alpha‐fetoprotein (AFP)
High
Normal/Neg
Lecithin/Sphingomyelin (LS) ratio
Don’t know/missing
Low
Don’t know/missing
__ . __
□
Trace
Phosphatidyl‐glycerol (PG)
□
□ □
Abnormal
□
Present
□
Absent
□
Don’t know/missing
□ □ □
Other abnormality
Yes
No
Don’t know/missing If yes, specify:______________________
Did the patient have an chorionic villus sampling (CVS) during the current pregnancy?
□ □ □ □
□ □ □
□ □ □
Yes
No
Refused
Chromosomal abnormality
Other abnormality
Yes
Don’t know
If yes, date: __ __ / __ __ / __ __
Yes
No
Don’t know/missing If yes, specify:______________________
No
Don’t know/missing If yes, specify:______________________
Gestational Diabetes Screening
Is patient known to have (pre‐existing) diabetes?
Glucose Tests:
□ □ □
Yes
No
Glucose ___ ___ ___ mg/dL
Date: __ __ / __ __ / __ __
Fasting?:
Glucose ___ ___ ___ mg/dL
Date: __ __ / __ __ / __ __
Fasting?:
Glucose ___ ___ ___ mg/dL
Date: __ __ / __ __ / __ __
Fasting?:
Glucose ___ ___ ___ mg/dL
Date: __ __ / __ __ / __ __
Fasting?:
Glucose ___ ___ ___ mg/dL
Date: __ __ / __ __ / __ __
Fasting?:
Glucose ___ ___ ___ mg/dL
Date: __ __ / __ __ / __ __
Fasting?:
Don’t know
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Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
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Don’t know
Don’t know
Don’t know
Don’t know
Don’t know
Don’t know
Glucose Tolerance Testing:
□ □ □
Did patient complete a 1‐hour, 50‐g glucose load random screening test?
Yes
No
Don’t know
If yes, result ___ ___ ___ mg/dL
Date of 1‐hour screening test: __ __ / __ __ / __ __
If yes, result ___ ___ ___ mg/dL
Date of 1‐hour screening test: __ __ / __ __ / __ __
If yes, result ___ ___ ___ mg/dL
Date of 1‐hour screening test: __ __ / __ __ / __ __
□ □ □
Did patient complete a 3‐hour, 100‐g glucose load test after overnight fasting?
Yes
No
Don’t know
If yes, results: Fasting ___ ___ ___ mg/dL
Date of 3‐hour test: __ __ / __ __ / __ __
1‐hour ___ ___ ___ mg/dL 2‐hour ___ ___ ___ mg/dL 3‐hour ___ ___ ___ mg/dL
Date of 3‐hour test: __ __ / __ __ / __ __
If yes, results: Fasting ___ ___ ___ mg/dL
1‐hour ___ ___ ___ mg/dL 2‐hour ___ ___ ___ mg/dL 3‐hour ___ ___ ___ mg/dL
If yes, results: Fasting ___ ___ ___ mg/dL
Date of 3‐hour test: __ __ / __ __ / __ __
1‐hour ___ ___ ___ mg/dL 2‐hour ___ ___ ___ mg/dL 3‐hour ___ ___ ___ mg/dL
Did the patient develop gestational diabetes during the current pregnancy?
If yes, date of diagnosis: __ __ / __ __ / __ __
Was patient given medication for diabetes during the current pregnancy?
□ □ □
Yes
No
Don’t know
□ □ □
Yes
No
Don’t know
If yes, type of medication (specify)______________________ Date started: __ __ / __ __ / __ __
Pregnancy‐Induced Hypertension
During the current pregnancy, was the patient ever diagnosed as having eclampsia, preeclampsia, toxemia, or
pregnancy‐induced hypertension?
□ □ □
Yes
No
Don’t know
If yes, date of diagnosis: __ __ / __ __ / __ __
Was patient given medication for hypertension during the current pregnancy?
□ □ □
Yes
No
Don’t know
If yes, type of medication (specify)______________________ Date started: __ __ / __ __ / __ __
Was patient ever hospitalized for hypertension‐related conditions during the current pregnancy?
□ □ □
Yes
No
Don’t know If yes, (specify reason)_____________________ Date: __ __ / __ __ / __ __
SYMPTOMS /FINDINGS
At any time during the current pregnancy, did the patient have any of the following symptoms or findings?
Severe headache
Mental status change
Visual disturbances
Right upper quadrant or epigastric pain
Oliguria
Pulmonary edema
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Yes
No
Don’t know
Yes
No
Don’t know
Yes
No
Don’t know
Yes
No
Don’t know
Yes
No
Don’t know
Yes
No
Don’t know
Seizures
Yes
No
Don’t know
Were any of the following noted as possible problems during the current pregnancy?
Oligohydramnios
Polyhydramnios
Fetal growth retardation (IUGR)
Large uterus for dates
Preterm labor, premature rupture of membranes
Other (specify____________________________)
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Yes
No
Don’t know
Yes
No
Don’t know
Yes
No
Don’t know
Yes
No
Don’t know
Yes
No
Don’t know
Yes
No
Don’t know
RESTRICTED ACTIVITY
Did the patient ever discontinue employment or reduce her usual activities (other than bedrest) during this pregnancy?
□ □ □
Yes
No
Don’t know
If yes, date first stopped working /reduced: __ __ / __ __ / __ __
□ □ □
Was the patient ever put on bedrest at home during this pregnancy?
Yes
No
Don’t know
If yes, date bedrest first started: __ __ / __ __ / __ __
TRANSFER OF CARE
Is there evidence in the medical record indicating that a part of the patient’s regular prenatal care was administered
elsewhere (at another clinic or facility)?
□ □ □
Yes
No
Don’t know
HOSPITALIZATIONS DURING PREGNANCY
Were there any hospitalizations during the current pregnancy?
If yes, date of admission: __ __ / __ __ / __ __
date of discharge: __ __ / __ __ / __ __
date of discharge: __ __ / __ __ / __ __
date of discharge: __ __ / __ __ / __ __
date of discharge: __ __ / __ __ / __ __
Specify reason for admission: _______________________________________________________
If yes, date of admission: __ __ / __ __ / __ __
Don’t know
Specify reason for admission: _______________________________________________________
If yes, date of admission: __ __ / __ __ / __ __
No
Specify reason for admission: _______________________________________________________
If yes, date of admission: __ __ / __ __ / __ __
Yes
Specify reason for admission: _______________________________________________________
If yes, date of admission: __ __ / __ __ / __ __
□ □ □
date of discharge: __ __ / __ __ / __ __
Specify reason for admission: _______________________________________________________
LABOR AND DELIVERY MEDICAL RECORD ABSTRACTION FORM
Admission Date __ __ / __ __ / __ __
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□
Admission Time ___ ___ : ___ ___ AM
□
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□
□ □
□
PM
Delivery Hospital:
Chinle
Gallup
Shiprock
Ft.Defiance
Tuba City
Other (Specify)_______________
MATERNAL CHARACTERISTICS AT ADMISSION
Maternal weight at admission _____ _____ _____ lb, _____ _____ oz. or
_____ _____. _____ kg
Maternal height at admission _____ ft, _____ _____ in.
or
_____ _____ _____ cm
Blood Pressure at admission: SBP__ __ __
DBP__ __
Cervical Dilation (cm) __ __ . __
Effacement (%)__ __
Onset of Labor: Date__ __ / __ __ / __ __
□
□ □ □
Station __ (‐3 to +3)
Check if no data
PM
Time ___ ___ : ___ ___ AM
ADMISSION COMPLICATIONS
Did any of the following conditions or problems occur during this admission, but prior to delivery?
Uterine bleeding, placenta previa/abruption
Premature rupture of membranes
Preterm labor
Secondary arrest/abnormal duration of labor
Failed forceps or vacuum
Cord prolapse
Shoulder dystocia
Meconium staining
Fetal distress
Amnionitis
Preeclampsia, eclampsia, toxemia, or
pregnancy‐induced hypertension
Other (Specify___________________________)
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Yes
No
Don’t know
Yes
No
Don’t know
Yes
No
Don’t know
Yes
No
Don’t know
Yes
No
Don’t know
Yes
No
Don’t know
Yes
No
Don’t know
Yes
No
Don’t know
Yes
No
Don’t know
Yes
No
Don’t know
Yes
No
Don’t know
□ □ □
Yes
No
Don’t know
Don’t know
DELIVERY CHARACTERISTICS
□
□
□ □
Attending Provider:
Obstetrician
□
Family Practice
□
Midwife
□
□
Other (Specify)__________
□
□
Don’t know
Type of Delivery:
Vaginal
Vaginal‐Assisted
Scheduled Cesarean
Emergency Cesarean
Don’t know
If delivery was an unscheduled C‐Section, what was reason(s) given? (specify)_________________________
Was the delivery induced using drugs to stimulate labor?
□ □ □
Yes
No
Don’t know
□ □
□ □
□ □
If yes, type? (specify)____________________________
When ___ ___ : ___ ___ AM
PM
If yes, type? (specify)____________________________
When ___ ___ : ___ ___ AM
PM
If yes, type? (specify)____________________________
When ___ ___ : ___ ___ AM
Which of the following methods of anesthesia were used during labor or delivery?
PM
Paracervical block, pudendal block, local infiltration
Epidural, spinal
No
Don’t know
Yes
No
Don’t know
Yes
No
Don’t know
□
Live birth
Yes
□ □ □
□ □ □
General
PREGNANCY OUTCOME
□
□ □ □
□
Stillbirth
□
Miscarriage
Don’t know
If Stillbirth or Miscarriage, Date __ __ / __ __ / __ __
□ □
□
Don’t know
□
Multiple fetuses?
Yes
No
If yes, number of live births
(If multiple birth, please complete birth characteristics for each infant below)
INFANT BIRTH CHARACTERISTICS
Infant 1:
□
Date of Birth __ __ / __ __ / __ __
□ □
Time of Birth ___ ___ : ___ ___ AM
PM
□
Sex
Male
Female
Weight _____ _____ lb, _____ _____ oz.
Length _____ _____ in
____ _____ _____ _____ gm
or
_____ _____ cm
or
Occipitofrontal head circumference _____ _____ in
or
_____ _____ cm
Gestational age at birth ____ ____ (weeks)
□
How estimated:
□
Ballard
□
Dubowitz
□
Other (Specify)_________________
Don’t know or missing
Apgar Scores: 1 minute ___ ___
□
10 minute ___ ___
□ □ □
Initiation of breastfeeding:
Infant 2:
5 minute ___ ___
Yes
No
Don’t know
□ □
Date of Birth __ __ / __ __ / __ __
Time of Birth ___ ___ : ___ ___ AM
PM
□
Sex
Male
Female
Weight _____ _____ lb, _____ _____ oz.
Length _____ _____ in
____ _____ _____ _____ gm
or
_____ _____ cm
or
Occipitofrontal head circumference _____ _____ in
_____ _____ cm
or
Gestational age at birth ____ ____ (weeks)
□
□
□
□
Ballard
Dubowitz
Other (Specify)_________________
Don’t know or missing
How estimated:
Apgar Scores: 1 minute ___ ___
5 minute ___ ___
10 minute ___ ___
□ □ □
Initiation of breastfeeding:
Infant 3:
□
Yes
No
Don’t know
Date of Birth __ __ / __ __ / __ __
□ □
Time of Birth ___ ___ : ___ ___ AM
PM
□
Male
Female
Sex
Weight _____ _____ lb, _____ _____ oz.
Length _____ _____ in
or
____ _____ _____ _____ gm
_____ _____ cm
or
Occipitofrontal head circumference _____ _____ in
_____ _____ cm
or
Gestational age at birth ____ ____ (weeks)
□
□
□
□
Ballard
Dubowitz
Other (Specify)_________________
Don’t know or missing
How estimated:
Apgar Scores: 1 minute ___ ___
5 minute ___ ___
10 minute ___ ___
□ □ □
Initiation of breastfeeding:
Yes
No
Don’t know
NEWBORN COMPLICATIONS DURING DELIVERY
Indicate if one or more newborns had any of the following complications during delivery:
Lacerations
Erb’s plasy/brachial plexus injury
Facial paralysis
□ □ □
□ □ □
□ □ □
Yes
No
Don’t know
Yes
No
Don’t know
Yes
No
Don’t know
Cephalohematoma
Fracture of skull, clavicle, or femur
Hyaline membrane disease (HMD)
Meconium aspiration
Nuchal cord
Respiratory distress
Seizures, intercranial hemorrhage
Congenital anomaly
Stillbirth
Nenonatal death
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
Yes
No
Don’t know
Yes
No
Don’t know
Yes
No
Don’t know
Yes
No
Don’t know
Yes
No
Don’t know
Yes
No
Don’t know
Yes
No
Don’t know
Yes
No
Don’t know
Yes
No
Don’t know
Yes
No
Don’t know
Yes
No
Don’t know
Admission to NICU
MATERNAL POSTPARTUM COMPLICATIONS
Indicate if mother had any of the following complications during or after delivery:
Bladder/ureteral injury
Bowel injury
Perineal lacerations/episiotomy extension
Abdominal wound infection
Endometritis
Pelvic abcess/cellulitis/septic pelvis
thrombophlebitis
Pneumonia
Sepsis
Deep vein thrombosis or pulmonary embolism
Yes
No
Don’t know
Yes
No
Don’t know
Yes
No
Don’t know
Yes
No
Don’t know
Yes
No
Don’t know
Yes
No
Don’t know
□ □ □
□ □ □
□ □ □
Yes
No
Don’t know
Yes
No
Don’t know
Yes
No
Don’t know
(confirmed)
Blood transfusion
□ □ □
□ □ □
Return to operating or delivery room
(Specify________________________)
DISCHARGE SUMMARY
Yes
No
Don’t know
Yes
No
Don’t know
□ □
Mother’s Discharge Date __ __ / __ __ / __ __ Mother’s Discharge Time ___ ___ : ___ ___ AM
PM
□ □ □
Status of mother at discharge:
Alive
Dead
Don’t know
□ □ □
Was infant(s) discharged at the same date/time as mother?
If no, date and time of infant(s) discharge:
Infant Discharge Date __ __ / __ __ / __ __
Yes
No
Don’t know
□ □
Infant Discharge Time ___ ___ : ___ ___ AM
PM
Study ID: __ __ __ __ __ __
Date completed (MM‐DD‐YY): __ __ / __ __ / __ __
Name of Abstracter:________________________________
□ □
Clinic:
Chinle
□
Gallup
□
Shiprock
Ft. Defiance
□
Tuba City
□
Other (Specify)________________
INFANT MEDICAL RECORD ABSTRACTION
(up to 1 year of Age)
Date of Birth __ __ / __ __ / __ __
Sex:
Is this child from a set of twins or a multiple birth?
□
□
Male
Female
□ □ □
Yes
No
Don’t know
If yes, siblings with:
Study ID __ __ __ __ __ __ Study ID __ __ __ __ __ __ Study ID __ __ __ __ __ __
Newborn Screening Results (within 24‐48 hours of birth)
Date of Test __ __ / __ __ / __ __
Did the child screen positive for any of the following conditions? (Check one box for each condition below)
Endocrine disorders:
1. Congenital Adrenal Hyperplasia (CAH)
2. Congenital hypothyroidism (CH)
Hemoglobinopathies:
3. Sickle Cell Anemia (HB S/S)
4. S‐βeta thalassemia (HB S/A)
5. Sickle C‐disease (HB S/C)
Other core condition(s):
6. Cystic Fibrosis (CF)
7. Biotinidase Deficiency (BIO)
8. Galactosemia (GALT)
□ □ □
□ □ □
Yes
No
Don’t know
Yes
No
Don’t know
□ □ □
□ □ □
□ □ □
Yes
No
Don’t know
Yes
No
Don’t know
Yes
No
Don’t know
□ □ □
□ □ □
□ □ □
Yes
No
Don’t know
Yes
No
Don’t know
Yes
No
Don’t know
9. Severe Combined Immunodeficiency Disorder (SCIDs)
Fatty Acid Oxidation disorders (FOA):
10. Carnitine uptake defect (CUD)
11. Long‐chain L‐3‐OH acyl‐CoA dehydrogenase deficiency
(LCHAD)
12. Medium chain acyl‐CoA dehydrogenase deficiency
(MCAD)
13. Trifunctional protein deficiency (TFP)
14. Very long‐chain acyl‐CoA dehydrogenase deficiency
(VLCAD)
Amino Acid Disorders:
15. Homocystinuria (HCY)
16. Tyrosinemia type I (TYR‐1)
17. Phenylketonuria (PKU)
18. Maple syrup urine disease (MSUD)
Urea Cycle disorders:
21. 3‐Hydroxy 3‐Methyl Glutaric Aciduria (HGM)
22. 3‐methylcrotonyl‐CoA deficiency (3‐MCC)
23. Beta‐kitothiolase /Mitochondrial acetoacetyl‐CoA thiolase
deficiency (BKT)
24. Isovaleric acidemia (IVA)
25. Methylmalonic acidemia (MUT)
19. Argininosuccinic acidemia (ASA)
20. Citrullinemia type I ( CIT‐1)
Organic Acidemia disorders:
□ □ □
Yes
No
Don’t know
□ □ □
□ □ □
Yes
No
Don’t know
Yes
No
Don’t know
□ □ □
Yes
No
Don’t know
□ □ □
□ □ □
Yes
No
Don’t know
Yes
No
Don’t know
□
□
□
□
□
□
□
□
□
□
□
□
Yes
No
Don’t know
Yes
No
Don’t know
Yes
No
Don’t know
Yes
No
Don’t know
□ □ □
□ □ □
Yes
No
Don’t know
Yes
No
Don’t know
□ □ □
□ □ □
□ □ □
Yes
No
Don’t know
Yes
No
Don’t know
Yes
No
Don’t know
□ □ □
□ □ □
Yes
No
Don’t know
Yes
No
Don’t know
26. Proponic acidemia (PROP)
27. Multiple carboxylase deficiency (MCD)
28. Glutaric acidemia type I (GA‐1)
Newborn Hearing Screening Test
Right ear:
Left ear:
□
□
Pass
Pass
□ □ □
□ □ □
□ □ □
Yes
No
Don’t know
Yes
No
Don’t know
Yes
No
Don’t know
□ □
Date of Test __ __ / __ __ / __ __
□
□
Refer
Refer
Time ___ ___ : ___ ___ AM
□
□
Don’t know
Don’t know
Newborn Screening Results (repeat, 1‐2 weeks after birth)
Date of Test __ __ / __ __ / __ __
Did the child screen positive for any of the following conditions? (Check one box for each condition below)
Endocrine disorders:
1. Congenital Adrenal Hyperplasia (CAH)
2. Congenital hypothyroidism (CH)
Hemoglobinopathies:
3. Sickle Cell Anemia (HB S/S)
4. S‐βeta thalassemia (HB S/A)
5. Sickle C‐disease (HB S/C)
Other core condition(s):
6. Cystic Fibrosis (CF)
7. Biotinidase Deficiency (BIO)
8. Galactosemia (GALT)
9. Severe Combined Immunodeficiency Disorder (SCIDs)
Fatty Acid Oxidation disorders (FOA):
10. Carnitine uptake defect (CUD)
□ □ □
□ □ □
Yes
No
Don’t know
Yes
No
Don’t know
□ □ □
□ □ □
□ □ □
Yes
No
Don’t know
Yes
No
Don’t know
Yes
No
Don’t know
□
□
□
□
□
□
□
□
□
□
□
□
Yes
No
Don’t know
Yes
No
Don’t know
Yes
No
Don’t know
Yes
No
Don’t know
□ □ □
Yes
No
Don’t know
PM
11. Long‐chain L‐3‐OH acyl‐CoA dehydrogenase deficiency
(LCHAD)
12. Medium chain acyl‐CoA dehydrogenase deficiency
(MCAD)
13. Trifunctional protein deficiency (TFP)
14. Very long‐chain acyl‐CoA dehydrogenase deficiency
(VLCAD)
Amino Acid Disorders:
15. Homocystinuria (HCY)
16. Tyrosinemia type I (TYR‐1)
17. Phenylketonuria (PKU)
18. Maple syrup urine disease (MSUD)
Urea Cycle disorders:
21. 3‐Hydroxy 3‐Methyl Glutaric Aciduria (HGM)
22. 3‐methylcrotonyl‐CoA deficiency (3‐MCC)
23. Beta‐kitothiolase /Mitochondrial acetoacetyl‐CoA thiolase
deficiency (BKT)
24. Isovaleric acidemia (IVA)
19. Argininosuccinic acidemia (ASA)
20. Citrullinemia type I ( CIT‐1)
Organic Acidemia disorders:
25. Methylmalonic acidemia (MUT)
26. Proponic acidemia (PROP)
27. Multiple carboxylase deficiency (MCD)
28. Glutaric acidemia type I (GA‐1)
□ □ □
Yes
No
Don’t know
□ □ □
Yes
No
Don’t know
□ □ □
□ □ □
Yes
No
Don’t know
Yes
No
Don’t know
□
□
□
□
□
□
□
□
□
□
□
□
Yes
No
Don’t know
Yes
No
Don’t know
Yes
No
Don’t know
Yes
No
Don’t know
□ □ □
□ □ □
Yes
No
Don’t know
Yes
No
Don’t know
□ □ □
□ □ □
□ □ □
Yes
No
Don’t know
Yes
No
Don’t know
Yes
No
Don’t know
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
Yes
No
Don’t know
Yes
No
Don’t know
Yes
No
Don’t know
Yes
No
Don’t know
Yes
No
Don’t know
2nd Hearing Test (repeat, 1‐2 weeks)
Right ear:
Left ear:
□
□
□
□
Pass
Time ___ ___ : ___ ___ AM
□
□
Refer
Pass
□ □
Date of Test __ __ / __ __ / __ __
Don’t know
Refer
Don’t know
Did child require a third newborn screening test (due to premature birth or NICU admission)?
□ □ □
Yes
No
Don’t know
If yes, Date of Test __ __ / __ __ / __ __
Regularly‐Scheduled Well‐Child Follow‐up Visits
Age: 1 week
Visit Date __ __ / __ __ / __ __
Weight _____ _____ lb, _____ _____ oz.
or
____ _____ _____ _____ gm
Length _____ _____ in
or
_____ _____ cm
Occipitofrontal head circumference _____ _____ in
Signs of abuse/neglect
_____ _____ cm
or
□ □ □
Yes
No
Don’t know
□ □ □
Has child reached appropriate developmental milestones?
Yes
No
Don’t know
□ □ □
Yes
No
Don’t know
Is child currently breastfeeding?
If yes, age when breastfeeding was initiated: ____ _____ hours ‐or‐
If no, was breastfeeding ever initiated?
_____ days
□ □ □
Yes
No
Don’t know
Age: 2 weeks
Visit Date __ __ / __ __ / __ __
Weight _____ _____ lb, _____ _____ oz.
or
____ _____ _____ _____ gm
Length _____ _____ in
or
_____ _____ cm
Occipitofrontal head circumference _____ _____ in
Signs of abuse/neglect
_____ _____ cm
or
□ □ □
Yes
No
Don’t know
□ □ □
Has child reached appropriate developmental milestones?
Yes
□ □ □
Yes
No
Is child currently breastfeeding?
Age: 6 weeks
Visit Date __ __ / __ __ / __ __
Don’t know
No
Don’t know
PM
Weight _____ _____ lb, _____ _____ oz.
Length _____ _____ in
or
____ _____ _____ _____ gm
or
_____ _____ cm
Occipitofrontal head circumference _____ _____ in
Signs of abuse/neglect
_____ _____ cm
or
□ □ □
Yes
No
Don’t know
□ □ □
Has child reached appropriate developmental milestones?
Yes
No
Don’t know
□ □ □
Yes
Is child currently breastfeeding?
No
Don’t know
Age: 4 months
Visit Date __ __ / __ __ / __ __
Weight _____ _____ lb, _____ _____ oz.
or
____ _____ _____ _____ gm
Length _____ _____ in
or
_____ _____ cm
Occipitofrontal head circumference _____ _____ in
Signs of abuse/neglect
_____ _____ cm
or
□ □ □
Yes
No
Don’t know
□ □ □
Has child reached appropriate developmental milestones?
ASQ Screening Test
Communication
__ __
Gross Motor
__ __
Fine Motor
__ __
Problem‐solving
__ __
Personal‐Social
__ __
Yes
No
Don’t know
□ □ □
Is child currently breastfeeding?
Yes
No
Don’t know
Age: 6 months
Visit Date __ __ / __ __ / __ __
Weight _____ _____ lb, _____ _____ oz.
or
____ _____ _____ _____ gm
Length _____ _____ in
or
_____ _____ cm
Occipitofrontal head circumference _____ _____ in
Signs of abuse/neglect
or
_____ _____ cm
□ □ □
Yes
No
Don’t know
Has child reached appropriate developmental milestones?
ASQ Screening Test
Communication
__ __
Gross Motor
__ __
Fine Motor
__ __
Problem‐solving
__ __
Personal‐Social
__ __
□ □ □
Yes
No
Don’t know
□ □ □
Is child currently breastfeeding?
Yes
No
Don’t know
Age: 9 months
Visit Date __ __ / __ __ / __ __
Weight _____ _____ lb, _____ _____ oz.
or
____ _____ _____ _____ gm
Length _____ _____ in
or
_____ _____ cm
Occipitofrontal head circumference _____ _____ in
Signs of abuse/neglect
or
_____ _____ cm
□ □ □
Yes
No
Don’t know
Has child reached appropriate developmental milestones?
ASQ Screening Test
Communication
__ __
Gross Motor
__ __
Fine Motor
__ __
Problem‐solving
__ __
Personal‐Social
__ __
□ □ □
Yes
No
Don’t know
□ □ □
Is child currently breastfeeding?
Yes
No
Don’t know
Age: 12 months
Visit Date __ __ / __ __ / __ __
Weight _____ _____ lb, _____ _____ oz.
or
____ _____ _____ _____ gm
Length _____ _____ in
or
_____ _____ cm
Occipitofrontal head circumference _____ _____ in
Signs of abuse/neglect
or
_____ _____ cm
□ □ □
Yes
No
Don’t know
Has child reached appropriate developmental milestones?
ASQ Screening Test
Communication
__ __
Gross Motor
__ __
Fine Motor
__ __
Problem‐solving
__ __
Personal‐Social
__ __
□ □ □
□ □ □
Yes
No
Don’t know
Is child currently breastfeeding?
Yes
No
Don’t know
Age when breastfeeding was discontinued: ____ _____ weeks or
____ _____ months
Age when solid food was introduced: ____ _____ weeks
or
____ _____ months
Blood Lead Test
_____ _____ . _____ mcg/dL
Date of test __ __ / __ __ / __ __
Information to be abstracted from medical record as available.
PREGNANCY
2nd trimester
13-26 weeks
serum Alpha-Fetal Protein (AFP) "quad" 4-part
also includes: hCG, estriol, inhibin
Chorionic villus sampling
Blood and Urine
Prenatal chart review
Blood pressure, vital signs, height, weight
Complete blood count (CBC): Anemia =
Hct<35%
ROM rupture of membranes
Glucose Tolerance Test (1-hour) plus 3hour if abnormal
Blood and Urine
Prenatal chart review
Blood pressure, vital signs, height, weight
Complete blood count (CBC): Anemia =
Hct<35%
3rd trimester
>27 weeks
ROM rupture of membranes
PROM premature rupture of membranes
UOP urine output
1st trimester
Before 13 weeks
Maternal
Baseline Questionnaire
Blood and Urine
Prenatal chart review
Blood pressure, vital signs, height, weight
Complete blood count (CBC): Anemia =
Hct<35%
Blood Type and Rh Antibody Screen
Glucose Tolerance Test (1-hour) plus 3-hour
if abnormal
HIV
PROM premature rupture of membranes
UOP urine output
Birth
6 weeks
POSTPARTUM
12 months
Breastfeeding patterns
Weight, length, head circumference
Growth curve results
Infections (number and type)
immunizations - to date
Diagnoses of any chronic conditions
Cause of mortality
Follow-up Questionnaire
Blood and Urine
Postpartum chart review
Blood pressure, vital signs, height, weight
DELIVERY
Blood and Urine
L&D chart review:
Blood pressure, vital signs, height, weight
Delivery complications
· Meconium staining (of amniotic fluid)
· Intrauterine hypoxia
· Fetal distress
· Stillbirth
Labor complications
- Precipitous labor
Hgb A1c
Serology (Rapid Plasma Reagin (RPR) for
Syphilis)
Rubella Titer
HBsAg (surface antigen of the Hepatitis-BVirus (HBV))
- Prolonged labor
- Shoulder dystocia
Pap Smear as needed
Urinalysis with Culture & Sensitivity
Urinalysis with Culture & Sensitivity
Group B Streptococcus (GBS)
Pregnancy-related medical conditions:
Pregnancy-related medical conditions:
- Hypertension (HTN), blood pressure
- Hypertension (HTN), blood pressure
- Preeclampsia/Eclampsia
- Preeclampsia/Eclampsia
- Preeclampsia with chronic HTN
- Preeclampsia with chronic HTN
- Gestational diabetes
- Gestational diabetes
- Hypothyroidism (including subclinical)
- Hypothyroidism (including subclinical)
- Autoimmune diseases
- Autoimmune diseases
- Anemia
- Anemia
- Other pregnancy-onset conditions
- Other pregnancy-onset conditions
- Breech presentation
Urinalysis with Culture & Sensitivity
- Nuchal cord
Delivery Type
Pregnancy-related medical conditions:
- Vaginal
- Hypertension (HTN), blood pressur
- Vaginal Assisted
- Preeclampsia/Eclampsia
- Scheduled Cesarean
- Preeclampsia with chronic HTN
- Emergency Cesarean
- Gestational diabetes
· Placental abruption
- Hypothyroidism (including subclinica
· Infection
- Autoimmune diseases
- STD
- Anemia
- TORCH
- Other pregnancy-onset conditions
- other bacterial
- other viral
· Postpartum complications
- Endometritis
- Hemorrhage
- Depression
GC Culture (Gonorrhea)
Chlamydia Culture
Fetal
Ultrasound
Kick counts (diary)
Gestational age (weeks)
Multiple fetuses
Fetal growth/ intrauterine growth restriction
Baby
Ultrasound
Cord blood
Kick counts (diary)
Birth chart review:
Gestational age (weeks)
Infant sex (altered sex ratio)
Multiple fetuses
Apgar scores
Fetal growth/ intrauterine growth restriction Neonatal complication
- Respiratory distress
- Meconium aspiration syndrome
- Neonatal jaundice
- Infection
Gestational age at birth
- Very preterm (<32 weeks)
- Preterm (<37 weeks)
- Postterm (>42 weeks)
Birth weight (BW)
- Very low BW (<1500g)
- Low BW (<2500g)
- Macrosomia (>4000g)
Birth length
OFC - Occipitofrontal circumference (head
circumference)
Congenital anomalies, major
Congenital anomalies, minor
· Hearing loss (screening results)
· Metabolic (screening results)
· Immunodeficiency
- Immune function markers
Mortality
- Neonatal (birth to <28 days)
- Postneonatal (>28 to 364 days)
- Infant (birth to 364 days)
· Sudden infant death syndrome (SIDS)
| File Type | application/pdf |
| File Title | Microsoft Word - Prenatal L&D Record Abstraction Form _draft 06-06-12_ |
| Author | Administrator |
| File Modified | 2013-02-06 |
| File Created | 2012-08-15 |