ºÚÁϳԹÏÍø Newborn Data Collection Form,,,,,,,,,,,,,,,,,,,,,,,
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Hospital ID,_____,Hospital name,_____,,,Chapter:,_____,,,Month/Year:,Mmm-yy,No. of Discharges,_____,,,,,,,,,,
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Patients No.,Patient's Initial,Date of Admission (MM/DD/YYYY),Term 0 = Preterm. 1 = Fullterm. 2 = Postterm,Gestational Age (Number of weeks and fraction of the week (e.g. 37 5/7),Weight (Kg),Weight / Gestational Age 0 = SGA. 1 = AGA. 2 = LGA. 3 = LBW,Presentation 0 = Breech. 1 = Cephalic. 2 = Transverse,Manner Delivery 0 = SVD. 1 = Forceps. 2 = CS. 3 = Vacuum. 4 = Breech Extraction,Sex 0 = Male. 1 = Female. 2 = Ambiguous,"Apgar Score (0-9, 0-9)",Diagnosis 1: Number and place of birth 0=singleton-in hospital 1=singleton-outside hospital 2=twin-in hospital 3=twin-outside hospital 4=multiple-in hospital,ICD no. 1 (Number and place of birth) 0= Z38.0 1=Z38.1 2=Z38.3 3=Z38.4 4=Z38.6,Diagnosis 2: Hyperbiliribunemia 0 - none. 1 = physiologic. 2 = breastfeeding. 3 = ABO incompatibility. 4 = prematurity 5 = other causes (free text),ICD no. 2 (Hyperbilirubinemia) 1 or 2 = P59.9 3 = P55.1 4 = P55.0 5 = must write ICD no.,Diagnosis 3: Respiratory 0 - normal. 1 = TTN . 2 = RDS. 3 = Pneumonia 4 = Asphyxia or free text,ICD no.3 (Respiratory) 1 = P22.1. 2 = P22.0. 3 = P23.9 4 = P21 ( write the correct ICD no.),Diagnosis 4: Sepsis 0 - none. 1 - Sepsis 2 - write cause ( free text),ICD no.4 (Sepsis) 1 - P36 2 = (must write ICD no.),Diagnosis 5: Congenital Diseases Write the diagnosis,ICD no.5 (write corresponding ICD no.),Birth outcome Live/Dead,Discharged outcome Live/Dead,Date Discharged (MM/DD/YYYY)