Microsoft word - appendix a - data collection form.doc

American Association of Birth Centers Data Form Revised - 02.10.2010
Data Entry Form: Part 1 ~ INITIAL OB VISIT
Name:___________________________________________________________ If Substance Abuse selected above, check all that apply: Patient ID:________________________________________________________ Pregnancy ID:________________ (auto-generated by UDS) 2. Payment Method
3. Secondary Insurance:______________________________________ 12. Pregnancy History (select all that apply) 4. Years of Education:________ (TOTAL # Years (GED=12) - NUMBERS ONLY 13. Number of Previous C-Sections:_______ If number of previous C-Sections >0 and planning a trial of labor (TOL),
please complete Part 1A - VBAC data
15. Intended Place of Birth for current pregnancy
16. Weeks Gestation at Start of Prental Care:_______ 9. Medical History (Check all that apply) 17. Weeks Gestation at Initial Visit to Birth Center or Midwifery Practice:________ Date of Initial Visit to Birth Center or Midwifery Practice:
_________________ (MMDDYYYY)
18. Estimated Due Date: _________________
END OF PART 1
PATIENT NAME:____________________________________________________ PATIENT ID:_____________________ PREGNANCY ID:_______________ Data Entry Form: Part 1A ~ VBAC DATA
13. Number of Previous C-Sections:_______ All reasons for c-section according to the mother If more than one previous c-section, use indication for the first c-section.
Primary Provider for pregnancy in which previous c-section was done Did you obtain operative note from previous c-section Mother’s level of commitment to having a VBAC No - but had other records that indicated type of uterine scar I think I want a VBAC right nowbut want to be able to change my mind in labor Mother’s reason for choosing OOH site for TOL (Skip this question if patient is planning an in-hospital VBAC) another c-section if I labor in the hospital ended in a c-sectionThe only hospital that will let me Primary reason for previous c-secion according to operative note: Yes - If the client has had a previous c-section and plans a VBAC, she has Non-reassuring FHR tracing/fetal distress been given verbal and written information about the risks and benefits ofboth a TOL and a repeat c-section. The pratice has on file her signed, writ- ten consent stating that she desires a TOL.
Yes - If an OOH VBAC is planned, the specific risks associated with an Interval from most recent c-section to current EDD OOH TOL have been discussed verbally and in writing, the practice has her signed consent on file indicating that she desires an OOH VBAC.
END OF PART 1A
Mother’s feelings about whether or not previous c-section(s) was (were) necessary Maybe - I think that it was probably necessary PATIENT NAME:____________________________________________________ PATIENT ID:_____________________ PREGNANCY ID:_______________ Data Entry Form: Part 2 ~ ANTEPARTUM COURSE
1. # of Prenatal Visits in Birth Center:_______ 2. # of Prenatal Visits with Other Providers:_______ Perinatal ConsultOther:_____________________________ Home Health Care:____________________________ Other:______________________________________ Prenatal Testing for Client Planning VBAC Ultrasound done specifically for placental localization Ultrasound done specifically for estimated feta weight at termOther intervention or testing done spcecifically because mother had had If Drugs selected above, check all that apply: 11. Prenatal Complication (select all that apply) 8. Prenatal Testing (Only those done as OUTPATIENT) NST/CST (Enter # of times test performed)
BPP/AFI ( Enter # of times test performed)
Amnio/CVS ( Enter # of times test performed)
Ultrasound ( Enter # of times test performed)
PATIENT NAME:____________________________________________________ PATIENT ID:_____________________ PREGNANCY ID:_______________ AABC UDS Data Entry Form Part 2 ~ AP Course page 2 Date AP Transfer/Left Care________________ (MMDDYYYY)
(If AP Medical Referral Selected)
If Attrition Medical select Primary Indication If Attrition Non-Medical select Primary Indication Was undecided about birthlocation at initial prenatal visit If AP Medical Referral select Primary Indication
13. Referral Disposition (leave blank if no transfer)
Remained in PracticeReferred out of Practice END OF PART 2
PATIENT NAME:____________________________________________________ PATIENT ID:_____________________ PREGNANCY ID:_______________ Data Entry Form: Part 3 ~ INTRAPARTUM COURSE
1. First Admission to Care
Methods Used for Induction and Locations Used (Select all that apply) 2. Date of First Admission:_________________ (MMDDYYYY)
3. Time of First Admission : (24 hr clock) 5. Primary Indication for Induction (select only 1) PATIENT NAME:____________________________________________________ PATIENT ID:_____________________ PREGNANCY ID:_______________ AABC UDS Data Entry Form Part 3 ~ IP Course page 2 IUPC - Average intensity of contraction byIUPC:_____mmHg 9. Pain Relief - Non-Pharmacological (select all that apply) 6. Primary Indication for Augmentation (select only 1) Methods Used for Augmentation and Locations Used (Select all that apply) 10. Pain Relief - Pharmacological (select all that apply) Cervical exam when initially received analgesia: 11. Other Procedures Used During Labor & Delivery (Select all that apply) 7. Monitoring During Labor (select all that apply) 12. Time from 1st digital exam after ROM until birth:_______ (HHMM) Initial Electronic Tracing, then Intermittent AuscultationContinuous Electronic If Intermittent Auscultation Only, specify: 14. Date of Birth of Infant:_________________ (MMDDYYYY)
15. Time of Birth of Infant : (24 hr clock) If Initial Electronic Tracing, then Intermittent Auscultation Only, specify: 16. Place of Birth
PATIENT NAME:____________________________________________________ PATIENT ID:_____________________ PREGNANCY ID:_______________ AABC UDS Data Entry Form Part 3 ~ IP Course page 3 17. Type of Birth
26. Intrapartum Transfer (from OOH site only)
Pre-Admission IP Referral Primary Indication: IP Emergency Transfer Primary Indication: 21. Support for Labor (check all that apply) Length of time from decision to transfer to arrival in receiving unit:__________ Length of time in hospital prior to delivery:_______ (HHMM) Provider Name:_____________________________________ Date of IP Transfer:_________________ (MMDDYYYY) 30. Intrapartum Complication (Select all that apply)
PATIENT NAME:____________________________________________________ PATIENT ID:_____________________ PREGNANCY ID:_______________ AABC UDS Data Entry Form Part 3 ~ IP Course page 4 36. Newborn Procedures (select all that apply) Uterine dehiscence - disruption of uterine muscle with intact serosa 31. Postpartum Transfer
Emergency Transfer Time:________ (minutes) Length of time from decision to transfer to arrival in receiving unit: Length of time in hospital prior to treatment:_______ (HHMM) Primary Indication for PP Transfer (Select only 1)
37. Date of Newborn Discharge:_____________ (MMDDYYYY) 38. Time of Newborn Discharge : (24 hr clock) Date of PP Transfer:_________________ (MMDDYYYY) 39. Type of Newborn Transfer
32. Postpartum Complication (select all that apply)
Length of time from decision to transfer to arrival in receiving unit: Length of time in hospital prior to treatment: _______ (HHMM) 40. Primary Indication for Newborn Transfer (select only 1)
33 Postpartum Procedures (select all that apply) If Congenital Anomalies, specify:______________________ 41. Date of Newborn Transfer from OOH:_____________ (MMDDYYYY) 42. Time of Newborn Transfer from OOH : (24 hr clock) 34. Date of Final Maternal Discharge:_____________ (MMDDYYYY) 35. Time of Final Maternal Discharge : (24 hr clock) PATIENT NAME:____________________________________________________ PATIENT ID:_____________________ PREGNANCY ID:_______________ AABC UDS Data Entry Form Part 3 ~ IP Course page 5 43. Pregnancy Outcome
51. Newborn Problems (select all that apply) Antepartum Death (IUFD before onset of labor) Intrapartum Death (IUFD after onset of labor) Died in utero at place of admissionIP transfer died in utero enroute If Congenital Anomalies, specify:_____________________ Date of Newborn Discharge from Transfer Site:_____________(MMDDYYYY) Infant transferred to hospital and died there Antepartum Death (IUFD before onset of labor) Intrapartum Death (IUFD after onset of labor) If Congenital Anomalies, specify:_____________________ Date of Newborn Discharge from Transfer Site:_____________(MMDDYYYY) Infant transferred but died enrouteInfant transferred to hospital and died there END OF PART 3
Breastmilk FeedingFormula FeedingCombination Breast/FormulaOther:__________________________________ Breastmilk FeedingFormula FeedingCombination Breast/FormulaOther:__________________________________ PATIENT NAME:____________________________________________________ PATIENT ID:_____________________ PREGNANCY ID:_______________ Data Entry Form: Part 4 ~ POSTPARTUM FOLLOW-UP
1. Date of Final Postpartum Visit or Date Determinted Lost to Follow-
Up:_________________ (MMDDYYYY)
2. Follow-Up
Follow-up to 6 weeksLost to Follow-up - Attempt Made (You are done!) Lost to Follow-Up - No Attempt (You are done!) 3 Home Visits:_______ (Enter # of visits) 4. Number of Maternal Birth Center Postpartum Visits:______ 5. Number of Maternal Postpartum Visits to Other Provider for Postpartum 15. Birth Control Method in Use After 6 Week PP Visit 6. Number of Infant Birth Center Visits:_______ 7. Number of Infant Visits to Other Providers:_______ 8. Number of Provider Initiated Phone Calls:_______ 9. Maternal Re-Admission Before 6 Weeks
Primary Indication for Maternal Re-Admission 16. Newborn Problem Up to 6 Weeks (select all that apply Length of Stay for Maternal Re-Admission: ______ days If Congenital Anomalies, specify:________________________ 10. Newborn Re-Admission Before 6 Weeks
If Newborn Death, explain:____________________________ Primary Indication for Newborn Re-Admission 18. If mother attempted a VBAC, what is her level of satisfaction with her trial of Length of Stay for Newborn Re-Admission: ______ days Happy that she attempted a VBAC at the birth center Age of Newborn at Re-Admission: ______ days Would have preferred a VBAC in the hospital 11. Maternal Problem Up to 6 Weeks Postpartum (select all that apply) Happy that she attempted a VBAC at the hospital Wishes that she had had a scheduled repeate c-section You have reached the end of AABC UDS Data Entry Form ☺

Appendix A - Data Collection Form.pdf

Source: http://www.birthcenters.org/sites/default/files/aabc/UDS%20Data%20Collection%20Form.pdf