ºÚÁϳԹÏÍø Newborn Data Collection Form,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
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Hospital ID,_____,Hospital name,_____,,,,,,,Month/Year:,Mmm-yy,No. of Live Births,_____,No. of Discharges,_____,No. of Deaths,_____,,,,,,,,,,,,,,,,,,,,
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Patients No.,Patient's Initial,Date of Admission (MM/DD/YYYY),Maturity: 0-Full Term(37W-41W). 1-Extremely PreTerm(27 and below). 2-Very PreTerm(28W-31W). 3-Moderate and Late Preterm (32W-36W). 4-Post term (42 weeks and above).,Gestational Age (Weeks),Weight (Grams),Weight for Gestational Age 0 = SGA. 1 = AGA. 2 = LGA,Presentation 0 = Cephalic. 1 = Breech. 2 = Transverse,Manner of 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, 0-9)",EINC: 0 - Completed 4 core steps. 1 - Incomplete. 2 - Not Done,Incomplete EINC Steps. 1-Immediate and thorough drying. 2-Skin to skin contact. 3-Properly timed cord clamping. 4-Non separation of the mother and baby,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,No. of fetuses (0-4),Patient Birth Location: 0 - Inborn. 1 - Outborn. 2 - Readmission(Up to 28 days),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.,Highest Total Bilirubin level (mg/dL) and age in days. Indicate highest bilirubin level reached (actual serum bilirubin in mg/dL) and day of life,Diagnosis 3: Respiratory 0 - normal lungs. 1 = TTN . 2 = RDS. 3 = Pneumonia,ICD no.3 (Respiratory) 1 = P22.1. 2 = P22.0. 3 = P23.9 4 = P21 ( write the correct ICD no.),Respiratory support: 0-IPPV. 1-NIPPV. 2-Nasal CPAP. 3-Nasal High Flow. 4-Face mask. 5-Nasal Cannula. 6-Blow by oxygen,Diagnosis 4: Sepsis 0 - none. 1 - Clinical Sepsis 2 - Culture Proven,ICD no.4 (Sepsis) 1 - P36 2 = (must write ICD no.),Diagnosis 5: Asphyxia 0 - No. 1 - Yes,ICD no.5 (Asphyxia) 1 - (must write ICD No.),Diagnosis 6: Congenital Diseases Write the diagnosis,ICD no.6 (write corresponding ICD no.),Diagnosis 7: Others,ICD no.7 (write corresponding ICD no.),Baby's COVID status. 0 - RTPCR Negative. 1 - RTPCR Positive Asymptomatic. 2 - Positive Mild.  3 - Positive Severe . 4 - Positive Critical. 5 - Unknown,Mother's COVID status. 0 - Covid Negative. 1 - RTPCR Positive. 2 - RAT Positive.  3 - Unknown,Kangaroo Mother Care (KMC) at the time of discharge: 0 - intermittent(< 20 hours). 1 - continuous (KMC ward or > 20 hours). 2 - not enrolled,Type of Feeding on Discharge. 0 - Exclusive Breastmilk. 1 - Mixed Feeding. 2 - Formula. 3 - None (Baby Died),Use of Donor Human Milk. 0 - No. 1 - Pasteurized Human Milk. 2 - Unpasteurized Human Milk,Discharge outcome Live/Dead,Date Discharged (MM/DD/YYYY)