Section 640

Section 640.APPENDIX I Perinatal Reporting System Data Elements

1. Child's First Name

2. Child's Middle Name

3. Child's Last Name

4. Child's Suffix

5. AKA

6. Child's Date of Birth

7. Child's Time of Birth

8. Sex

A. Male

B. Female

C. Ambiguous

9. Child of Hispanic Origin

A. Yes

Cuban

Mexican

Puerto Rican

B. No

10. Race

A. Asian

B. Black

C. Caucasian

D. Native American

E. Other

11. Place of Birth

12. City of Birth

13. County of Birth

14. Mother's First Name

15. Mother's Middle Name

16. Mother's Last Name

17. Mother's Maiden Name

18. Mother's Social Security Number

19. Mother's Date of Birth

20. Mother's Street Number

21. Mother's Street Name

22. Mother's Street Direction

23. Mother's Street Type

24. Mother's Street Location

25. Mother's City

26. Mother's County

27. Mother's Zip Code

28. Mother's State

29. Mother's Telephone

30. Mother's Age

31. Mother's Birthplace

A. ________State

B. ________County

32. Mother of Hispanic Origin

A. Yes

Cuban

Mexican

Puerto Rican

B. No

33. Mother's Race

A. Asian

B. Black

C. Caucasian

D. Native American

E. Other

34. Mother's Education (specify highest grade completed)

35. Mother's Occupation

_________________

36. Mother's Business/Industry

37. Mother Employed During Pregnancy

A. Yes

B. No

C. Record Not Available (N/A)

D. Not Stated

38. Marital Status

A. Married

B. Not Married

39. Father's Last Name

40. Father's Middle Name

41. Father's First Name

42. Father of Hispanic Origin

A. Yes

Cuban

Mexican

Puerto Rican

B. No

43. Father's Race

A. Asian

B. Black

C. Caucasian

D. Native American

E. Other

44. Father's Education (specify highest grade completed)

45. Father's Age

46. Father's Occupation

________________

47. Father's Business/Industry

__________________

48. Father Employed

A. Yes

B. No

C. Record N/A

D. Not Stated

49. Pregnancy History

50. Plurality (# this Birth)

If greater than 1, Birth Order of this Birth

51. Previous Live Births

52. Number Live Births Now Living

53. Number Live Births Now Dead

54. Date of Last Live Birth

55. Previous Terminations

56. Number of Other Terminations

57. Date of Last Other Termination

58. Date of Last Normal Menses

59. Month Prenatal Care Began

60. Number of Prenatal Care Visits

61. 1 Minute Apgar Score

62. 5 Minute Apgar Score

63. Estimate of Number of Gestation Weeks

64. Mother Transferred In Prior to Delivery

A. Yes

B. Name of Hospital ________________

Location of Hospital ________________

C. No

65. Infant Transferred (Out)

A. Yes

B. Name of Hospital ____________

Location of Hospital _____________

C. Transfer Code

D. No

66. Reporting Hospital

67. Reporting Hospital City

68. Tobacco Use During Pregnancy

A. Smoked during pregnancy

Average cigarettes per day _____________

B. Stopped smoking during pregnancy

C. Does not smoke

D. Record N/A

E. Not Stated

69. Alcohol Use During Pregnancy

A. Yes

Average number drinks per day ______

B. No

C. Record N/A

D. Not Stated

70. Mother's Weight Gain

A. Yes

Pounds ______

B. No

C. Record N/A

D. Not Stated

71. Mother's Weight Loss

A. Yes

Pounds ______

B. No

C. Record N/A

D. Not Stated

72. Medical Risk Factors for this Pregnancy

A. Anemia

B. Cardiac Disease

C. Acute or Chronic Lung Disease

D. Diabetes

E. Genital Herpes

F. Hydramnios/Oligohydramnios

G. Hemoglobinapathy

H. Hypertension, Chronic

I. Hypertension, Pregnancy-related

J. Eclampsia

K. Incompetent Cervix

L. Previous Infant 4000 + Grams

M. Previous Preterm or Small-for-Gestational-Age (SGA) Infant

N. Renal Disease

O. Rh Sensitization

P. Uterine Bleeding

Q. None

R. Other, Specify

73. Obstetric Procedures

A. Amniocentesis

B. Electronic Fetal Monitoring

Internal

External

Both

Neither

Record N/A

Not Stated

C. Induction of Labor

D. Stimulation of Labor

Yes

Pitocin _____

Oxytocin _____

Record N/A

Not Stated

E. Tocolysis

F. Ultrasound

G. None

H. Other, Specify

74. Complications of Labor and/or Delivery

A. Febrile

B. Meconium

C. Premature Rupture

D. Abruptio Placenta

E. Placenta Previa

F. Other Excessive Bleeding

G. Seizures During Labor

H. Precipitous Labor

I. Prolonged Labor

J. Dysfunctional Labor

K. Breech/Malpresentation

L. Cephalopelvic Disportion

M. Cord Prolapse

N. Anesthetic Complications

O. Fetal Distress

P. None

Q. Other, Specify

75. Method of Delivery

A. Spontaneous Vaginal

B. Mid – Low Forceps

C. Vacuum Extraction

D. Vaginal Breech

E. Caesarean Section Primary

F. Caesarean Section Repeat

G. Other Type

H. Record N/A

I. Not Stated

J. Vaginal Birth After Previous Caesarean Section (VBAC)

K. Other Caesarean Section

76. Abnormal Conditions of Newborn

77. Anemia

78. Birth Injury

79. Fetal Alcohol Syndrome

80. Hyaline Membrane Disease

81. Meconium Aspiration Syndrome

82. Assisted Ventilation > 30 min.

83. Assisted Ventilation = 30 min.

84. Seizures

85. Human Immunodeficiency Virus (HIV)

86. Other, Specify

87. Congenital Anomolies of Newborn

88. Anencephalous

89. Congenital Syphilis

90. Hypothyroidism

91. Adrenogenital Syndrome

92. Inborn Errors of Metabolism

93. Cystic Fibrosis

94. Immune Deficiency Disorder

95. Retinopathy of Prematurity

96. Chorioretinitis

97. Strabismus

98. Intrauterine Growth Restriction

99. Cerebral Lipidoses

100. Spina Bifida/Meningocele

101. Hydrocephalus

102. Microcephalus

103. Other CNS Anomalies, Specify ____________

104. Heart Malformations, Specify _____________

105. Other Circulatory/Respiratory Anomalies, Specify ____________

106. Rectal Atresia/Stenosis

107. Tracheoesophageal Fistula/Esophageal Atresia

108. Omphalocele/Gastrochisis

109. Other Gastrointestinal Anomaly

110. Malformed Genitalia

111. Renal Agenesis

112. Other Urogenital Anomaly, Specify ____________

113. Cleft Lip/Palate, Specify ____________

114. Polydactyly/Syndactyly/Adactyly

115. Club Foot

116. Diaphragmatic Hernia

117. Other Musculoskeletal/Integumental Anomaly

118. Down's Syndrome

119. Other Chromosomal Anomaly, Specify ____________

120. None

121. Other, Specify ____________

122. Transfusion

123. Anesthesia

A. Local/Pudenal

B. Regional

C. General

124. Umbilical Cord Blood Gases Tested

A. Yes

B. No

125. Small-for-Gestational-Age (SGA)

126. Infection of Newborn Acquired Before Birth

127. Infection of Newborn Acquired During Birth

128. Infection of Newborn Acquired After Birth

129. Hereditary Hemolytic Anemias

130. Hemolytic Diseases of the Newborn

131. Due to Rh Incompatibility Only

132. Due to ABO Incompatibility

133. Due to Other Causes

134. Drug Toxicity or Withdrawal

A. Yes, Specify ____________

B. No

135. Highest Bilirubin, Total ________

136. Admit to Designated Patient Unit

A. Yes

B. No

137. Genetic Screenings Conducted

138. Rh Determination

A. Mother's Blood Type _______ Rh Factor _______

Immune Globulin Given

B. Yes

C. No

139. Hepatitis B – Surface Antigen

A. Positive

B. Negative

140. Non-Obstetrical Infections

A. Syphilis

B. Gonorrhea

C. Rubella

D. Other

141. Obstetrical Infections

A. Antepartum

Amnionitis/Chioramnionitis

Urinary Tract Infection

B. Postpartum

Endometritis

Infection of Wound

Urinary Tract Infection

142. Mother admitted within 72 hours after delivery

A. Precipitous Delivery

B. Planned Home Birth

143. Drug Use During Pregnancy

A. Cocaine

B. Heroin

C. Marijuana

D. Other Street Drugs

E. None

F. Record N/A

G. Not Stated

144. Transfusion

145. Prenatal Screening Conducted for

A. Gestational Diabetes

(Blood Glucose Tolerance Test)

B. Congenital/Birth Defects

A. Maternal Alpha Feta Protein

B. Chromosomal

C. Other

146. Number of Days Maintained on Ventilation Before Transfer to Level III Center-Days

147. Prenatal Ultrasound

A. Yes

B. No

C. Record N/A

D. Not Stated

148. Chorionic Villus Sampling

149. Were Newborn Screening Tests Conducted?

A. Yes

B. No

150. Mother Transferred Out to Another Hospital After Delivery Destination Hospital Code

151. Mother Transferred From Emergency Room

152. Infant Transferred In Transfer Code

153. Consult Administrative Perinatal Center or Another Level III

154. Infant Maternal

A.	A.	Yes, with Transfer

B.	B.	Yes, No Transfer

C.	C.	No Consultation

D.	D.	Not Stated

155. Mother Died In Hospital

156. Fetal Death

157. Infant Died in Hospital

158. Extrauterine Pregnancy

159. Ectopic Pregnancy

160. Admission Date – Infant

161. Admission Date – Maternal

162. Discharge Date – Infant

163. Discharge Date – Maternal

164. Payment Method

A. Yes

Medicaid

Medicaid HMO

HMO

Medicare

CHAMPUS

Title V

Health Insurance

Self Pay

Not Stated

Other, Specify __________

B. No

165. Were prenatal records available prior to delivery?

A. Yes

B. No

166. Maternal Diagnosis (Specify up to 8 Diagnoses)

167. Mother's Medical Record Number _________________

168. Infant Diagnoses (Including Congenital Anomalies); Specify up to 8 Diagnoses

169. Infant Released to:

A. Home

B. Other Hospital	Name and Location

C. Long Term Care	Name and Location

D. Other Child Care Agency	Name and Location

170. Infant Patient ID

171. Infant Medical Record Number __________________

172. Referrals

A. Community Social Services

B. Division of Specialized Services for Children (DSCC)

C. Department of Healthcare and Family Services (HFS)

D. Department of Children and Family Services (DCFS)

E. Other, Specify _________________

F. None

G. Early Intervention program

H. Other _______________

173. Feedings

174. Breast Fed

175. Bottle

176. Tube

177. Formula

178. Frequency

179. Amount

180. Infant Medications

181. Birth Weight

182. Birth Head Circumference

183. Birth Length

184. Discharge Weight

185. Discharge Head Circumference

186. Discharge Length

187. Infant Discharge Treatment

188. Other Concerns

189. RN Contact at Hospital – Phone Number

190. Relative/Friend

191. Relationship

192. Address/Phone #

193. Family Informed of Local Health Nurse Visit

A. Yes

B. No

194. Primary Care Physician's Name –

195. Mother Gravida Para F_ P_ A_ L_

196. Signature

197. Title

198. Report Date

(Source: Amended at 35 Ill. Reg. 2583, effective January 31, 2011)