"Medical Data Worksheet for Child's Birth Certificate" - Texas

Medical Data Worksheet for Child's Birth Certificate is a legal document that was released by the Texas Department of State Health Services - a government authority operating within Texas.

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Download "Medical Data Worksheet for Child's Birth Certificate" - Texas

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VS-109.2 (09/11)
Medical Data Worksheet for Child’s Birth Certificate
This form to be completed by hospital staff. This data will be used to populate the medical data portion of the birth
certificate for the newborn. The medical data is required to be reported within five days of the birth. [HSC
§192.003]
PATIENT REFERRENCE:
MOTHER MR# _________________________________________
NEWBORN MR# ___________________________________________
MOTHER’S NAME ______________________________________
NEWBORN NAME _________________________________________
MEDICAID# ___________________________________________
DOB ____________________________________________________
DELIVERING DR _______________________________________
DATE AOP SENT__________________________________________
MOTHER TRANSFERRED _______________________________
SOURCE OF PAYMENT FOR DELIVERY ______________________
Born at Facility
Born En Route
Foundling
Home Birth
Prenatal Care
Source of Prenatal Care
Yes
No
Unknown
(check all that apply)
____/____/______
None
Midwife
Date of First Visit
__________________
Hospital Clinic
Other, Specify
____/____/______
Date of Last Visit
Public Health Clinic
Unknown
Total Number of Prenatal Visits for this Pregnancy: ________
Private Physician
___/___/_____
Date Last Normal Menses Began
Risk Factors in this Pregnancy
(check all that apply)
Pregnancy History
Diabetes
Live births now living (Do not include this birth. For multiple
Prepregnancy (diagnosis prior to this pregnancy)
st
deliveries, do not include the 1
born in the set if completing
_____
Gestational (diagnosis in this pregnancy)
this worksheet for that child. If none enter “0”.):
Live births now dead (Do not include this birth. For multiple
Hypertension
st
deliveries, do not include the 1
born in the set if completing
Prepregnancy (chronic)
_____
this worksheet for that child. If none enter “0”.):
Gestational (PIH, preeclampsia)
____/______
Date of last live birth:
Eclampsia
MM YYYY
Previous preterm birth
Number of other pregnancy outcomes (Include fetal losses
of any gestational age. If this was a multiple delivery, include
Other previous poor pregnancy outcome (includes perinatal death, small-for-
all fetal losses delivered before this infant in the pregnancy.
gestational age/intrauterine growth restricted birth)
_____
If none enter “0”.):
Pregnancy resulted from infertility treatment
____/______
Date of last other pregnancy outcome:
Fertility-enhancing drugs, artificial
MM YYYY
insemination or intrauterine insemination
Infections Present and/or Treated During
Assisted reproductive technology
Pregnancy
(check all that apply)
Mother had a previous cesarean delivery
_____
If yes, how many?
Gonorrhea
Hepatitis B
Antiretrovirals administered during pregnancy or at delivery
Syphilis
Hepatitis C
Chlamydia
None of the above
None of the above
HIV Test
HIV test done Prenatally
Yes
No
Unknown
HIV test done at Delivery
Yes
No
Unknown
(check all that apply)
First Trimester
Third Trimester
Infant tested for HIV at birth
Yes
No
Unknown
Second Trimester
Unknown
None
VS-109.2 (09/11)
Medical Data Worksheet for Child’s Birth Certificate
This form to be completed by hospital staff. This data will be used to populate the medical data portion of the birth
certificate for the newborn. The medical data is required to be reported within five days of the birth. [HSC
§192.003]
PATIENT REFERRENCE:
MOTHER MR# _________________________________________
NEWBORN MR# ___________________________________________
MOTHER’S NAME ______________________________________
NEWBORN NAME _________________________________________
MEDICAID# ___________________________________________
DOB ____________________________________________________
DELIVERING DR _______________________________________
DATE AOP SENT__________________________________________
MOTHER TRANSFERRED _______________________________
SOURCE OF PAYMENT FOR DELIVERY ______________________
Born at Facility
Born En Route
Foundling
Home Birth
Prenatal Care
Source of Prenatal Care
Yes
No
Unknown
(check all that apply)
____/____/______
None
Midwife
Date of First Visit
__________________
Hospital Clinic
Other, Specify
____/____/______
Date of Last Visit
Public Health Clinic
Unknown
Total Number of Prenatal Visits for this Pregnancy: ________
Private Physician
___/___/_____
Date Last Normal Menses Began
Risk Factors in this Pregnancy
(check all that apply)
Pregnancy History
Diabetes
Live births now living (Do not include this birth. For multiple
Prepregnancy (diagnosis prior to this pregnancy)
st
deliveries, do not include the 1
born in the set if completing
_____
Gestational (diagnosis in this pregnancy)
this worksheet for that child. If none enter “0”.):
Live births now dead (Do not include this birth. For multiple
Hypertension
st
deliveries, do not include the 1
born in the set if completing
Prepregnancy (chronic)
_____
this worksheet for that child. If none enter “0”.):
Gestational (PIH, preeclampsia)
____/______
Date of last live birth:
Eclampsia
MM YYYY
Previous preterm birth
Number of other pregnancy outcomes (Include fetal losses
of any gestational age. If this was a multiple delivery, include
Other previous poor pregnancy outcome (includes perinatal death, small-for-
all fetal losses delivered before this infant in the pregnancy.
gestational age/intrauterine growth restricted birth)
_____
If none enter “0”.):
Pregnancy resulted from infertility treatment
____/______
Date of last other pregnancy outcome:
Fertility-enhancing drugs, artificial
MM YYYY
insemination or intrauterine insemination
Infections Present and/or Treated During
Assisted reproductive technology
Pregnancy
(check all that apply)
Mother had a previous cesarean delivery
_____
If yes, how many?
Gonorrhea
Hepatitis B
Antiretrovirals administered during pregnancy or at delivery
Syphilis
Hepatitis C
Chlamydia
None of the above
None of the above
HIV Test
HIV test done Prenatally
Yes
No
Unknown
HIV test done at Delivery
Yes
No
Unknown
(check all that apply)
First Trimester
Third Trimester
Infant tested for HIV at birth
Yes
No
Unknown
Second Trimester
Unknown
None
Obstetric Procedures
Onset of Labor
(check all that apply)
(check all that apply)
Cervical cerclage
Premature Rupture of the Membranes [prolonged > =12 hours]
Tocolysis
Precipitous Labor [< 3 hours]
Prolonged Labor [> = 20 hours]
External cephalic version
Successful
Failed
None of the above
None of the above
Method of Delivery
Was delivery with forceps attempted but unsuccessful?
Characteristics of Labor & Delivery
Yes
No
Unknown
(check all that apply)
Was delivery with vacuum extraction attempted but unsuccessful?
Induction of labor
Yes
No
Unknown
Augmentation of labor
Fetal presentation at birth
Non-vertex presentation
Cephalic
Breech
Other, _________________________
Steroids (glucocorticoids) for fetal lung maturation
Final route and method of delivery
received by mother prior to delivery
Vagina/Spontaneous
Vagina/Forceps
Vagina/Vacuum
Antibiotics received by mother during labor
If cesarean, was a trial of labor attempted?
Cesarean
Chorioamnionitis or maternal temperature > = 38 degrees C or
Yes
No
Unknown
100.4 degrees F
Moderate/heavy meconium staining of the amniotic fluid
Child’s Health Information
Fetal intolerance of labor was such that one or more of the
Grams, or
LB.
OZ.
________
________
________
Birth Weight
following actions was taken: in-utero resuscitative measures,
further assessments, or operative delivery
_________
Obstetric Estimate of Gestation (completed weeks):
Epidural or spinal anesthesia during labor
Child’s Sex:
Male
Female
Not yet determined
None of the above
Apgar Score: at 5 min:_______; (if less than 6) at 10 min:_______
Maternal Morbidity – Complications associated
Abnormal Conditions of the Newborn
(check all that apply)
with Labor & Delivery
(check all that apply)
Assisted ventilation required immediately following delivery
Maternal transfusion
Assisted ventilation required for more than six hours
Third or forth degree perineal laceration
NICU admission
Ruptured uterus
Newborn given surfactant replacement therapy
Unplanned hysterectomy
Antibiotics received by the newborn for suspected neonatal sepsis
Admission to intensive care unit
Seizure or serious neurologic dysfunction
Unplanned operating room procedure following delivery
Significant birth injury (skeletal fracture(s), peripheral nerve injury, and/or
soft tissue/solid organ hemorrhage which requires intervention)
None of the above
None of the above
Congenital Anomalies of the Newborn
(check all that apply)
Anencephaly
Cleft palate alone
Was Infant Transferred within 24 hours
of
Delivery?
_________________
Meningomyelocele/Spina bifida
Down syndrome
No
Yes, Specify Facility
Karyotype confirmed
Cyanotic congenital heart disease
Is Infant Living at Time of Report?
Karyotype pending
Congenital diaphragmatic hernia
Yes
No
Omphalocele
Suspected chromosomal disorder
Karyotype confirmed
Is Infant Being Breastfed at Discharge?
Gastroschisis
Karyotype pending
Yes
No
Limb reduction defect
(excluding congenital amputation
Hypospadias
and dwarfing syndromes)
Hepatitis B Immunization given?
Cleft lip with or without Cleft palate
None of the above
Yes
No
VS-109.2 (09/11)
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