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Nova Scotia Atlee Perinatal Database Coding Manual 7Th Edition

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Nova Scotia Atlee Perinatal Database Coding Manual 7Th Edition Nova Scotia Atlee Perinatal Database Coding Manual 7th Edition (REVISED) Reprinted January 2000 NOVA SCOTIA ATLEE PERINATAL DATABASE CODING MANUAL TABLE OF CONTENTS (A) ROUTINE INFORMATION LISTING OF HOSPITALS .......................1 DELIVERED ADMISSIONS ......................3 UNDELIVERED ADMISSIONS ..................59 POSTPARTUM ADMISSIONS ...................69 NEONATAL ADMISSIONS .................... 79 ANOMALY ADMISSIONS ......................91 (B) CLASSIFICATION OF MATERNAL DISEASES AND PROCEDURES (Blue Section) I. Previous Pregnancy Maternal Diseases.............. 01 II. Present Pregnancy Maternal Diseases............... 02 A. Obstetrical ..............................02 B. Non-Obstetrical..........................07 C. Labour Complications .....................15 D. Non-Delivery Procedures ..................16 E. Analgesia During Labour ...................20 F. Anesthesia During Labour/Delivery ..........22 G. Anesthesia for Non-Delivery Procedures ......24 H. Lacerations ..............................25 I. Postpartum Complications..................26 J. Postpartum Infections .....................29 K. Maternal Therapy.........................31 L. Maternal Death or Undelivered Fetal Death....33 M. Infection in Present Pregnancy .............34 N. Complications of Anesthesia................37 O. Antibiotic Therapy........................39 P. Fetal Procedures..........................40 Q. Methods of Induction ......................41 7th Edition, April 2001, V7.2 Table of Contents and Index i NOVA SCOTIA ATLEE PERINATAL DATABASE CODING MANUAL C. CLASSIFICATION OF NEONATAL DISEASES AND PROCEDURES (Pink Section) I. Placenta and Umbilical Cord Anomalies ..............01 II. Fetal Malnutrition ...............................02 III. Congenital Anomalies A. Cardiovascular Anomalies..................03 B. Gastro-Intestinal Anomalies ................07 C. Respiratory Anomalies ....................09 D. Eye, Ear, Nose, Mouth, Throat Anomalies .....10 E. Anomalies of Inguinal Canal ................13 F. Genitourinary Anomalies...................14 G. Skin Anomalies ..........................17 H. Musculoskeletal Anomalies.................19 I. Central Nervous System Anomalies ..........22 J. Multiple Anomalies .......................26 IV. Asphyctic Conditions .............................30 V. Trauma .......................................32 VI. Infections......................................35 A. Infectious Diseases .......................35 B. Chronic Intra-Uterine Infections.............39 C. Acute Viral Infections.....................40 D. Miscellaneous Infections...................41 VII. Central Nervous System Diseases ...................42 VIII. Respiratory Diseases ............................46 IX. Gastrointestinal Diseases..........................49 X. Hematologic Diseases............................51 XI. Endocrine Diseases ..............................57 XII. Metabolic Diseases ..............................59 XIII. Miscellaneous Disorders .........................63 XIV.Treatments and Procedures ........................69 XV. Twins .......................................77 XVI.Miscellaneous ..................................78 7th Edition, April 2001, V7.2 Table of Contents and Index ii NOVA SCOTIA ATLEE PERINATAL DATABASE CODING MANUAL (D) MATERNAL DISEASE/PROCEDURE INDEX ......01 ( Blue section) (E) NEONATAL DISEASE/PROCEDURE INDEX .......01 (Pink Section) 7th Edition, April 2001, V7.2 Table of Contents and Index iii NOVA SCOTIA ATLEE PERINATAL DATABASE CODING MANUAL “LEFT BLANK INTENTIONALLY” 7th Edition, April 2001, V7.2 Table of Contents and Index iv NOVA SCOTIA ATLEE PERINATAL DATABASE CODING MANUAL INDEX FOR ROUTINE INFORMATION-DELIVERED ADMISSIONS Abdominal Circumference ..............................49 Abortions .......................................14 Admitted from .......................................12 Antepartum bleeding..................................17 A/S/D number ........................................4 Attendance at prenatal classes...........................21 Attending physician ...................................10 Biparietal Diameter ...................................48 Birthdate ........................................5 City/Town .......................................10 Crown/Rump Length..................................48 Date of LNMP.......................................13 Date of admission .....................................3 Date of first ultrasound ................................47 Delivery Physician....................................43 Femur Length .......................................49 Given name(s) ........................................4 Gravida .......................................13 Head Circumference ..................................49 Health Card Number ...................................5 Hospital of delivery...................................12 Intent to breastfeed....................................17 Mail Address ........................................9 Marital status ....................................... 9 Municipal code .......................................6 Para .......................................13 Pre-conceptual folate intake.............................13 Postal Code ........................................9 Present weight .......................................23 Pre-pregnant weight...................................19 Pre-pregnancy smoking................................16 Previous breastfeeding experience........................17 Previous c-sections ...................................14 Previous fetal deaths ..................................14 Previous gyne surgery .................................18 Previous low birth weight infants ........................15 Previous neonatal deaths...............................14 7th Edition, April 2001, V7.2 Table of Contents and Index v NOVA SCOTIA ATLEE PERINATAL DATABASE CODING MANUAL INDEX FOR ROUTINE INFORMATION-DELIVERED ADMISSIONS Previous overweight infants.............................15 Previous postpartum hemorrhage ........................15 Process status .......................................11 Reason for admission..................................20 Rh factor .......................................19 Rh immune globulin - antepartum........................20 Smoking at time of delivery.............................22 Smoking at first prenatal visit ...........................16 Street Address ........................................9 Surname ........................................4 Time of admission.................................... 4 Unit number ........................................3 7th Edition, April 2001, V7.2 Table of Contents and Index vi NOVA SCOTIA ATLEE PERINATAL DATABASE CODING MANUAL INDEX FOR ROUTINE INFORMATION-LABOUR AND INFANT Abdominal circumference measurement ...................49 Apgar score .......................................42 ASA classification....................................46 A/S/D number .......................................50 Autopsy .......................................56 Base excess value.....................................53 Biparietal diameter measurement ........................48 Birth Order .......................................25 Birth weight .......................................42 Breastfeeding .......................................55 Clinical gestation.....................................52 Cord artery acid-base..................................52 Cord artery pH value..................................53 Crown/rump length measurement ........................48 Date of first ultrasound ................................47 Date of medical augmentation...........................33 Date of rupture of membranes...........................26 Date/time of admission to LDR ..........................31 Date of birth .......................................37 Date/time of death ....................................58 Date/time of 4 cm dilatation ............................35 Date/time of second stage ..............................36 Dilatation at c-section .................................40 Dilatation at medical augmentation.......................34 Dilatation on admission to LDR .........................32 Discharge date/time - infant .............................55 Discharge date/time - mother ............................44 Discharged to - infant .................................56 Discharged to - mother ................................46 Episiotomy .......................................41 Femur length measurement .............................49 Given name(s) .......................................25 Head circumference measurement........................49 Health card number...................................51 Indication for induction ................................30 Infant’s Primary Cause of Death.........................57 7th Edition, April 2001, V7.2 Table of Contents and Index vii NOVA SCOTIA ATLEE PERINATAL DATABASE CODING MANUAL INDEX FOR ROUTINE INFORMATION-LABOUR AND INFANT Labour .......................................29 Meconium staining ...................................28 Medical augmentation.................................32 Method of delivery ....................................38 Mode of delivery.....................................37 Number of fetuses ....................................26 Outcome of infant ....................................54 PC02 value .......................................53 Physician attending delivery ............................43 Physician - infant’s ...................................51
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