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2020 CDA Paper Abstraction Forms

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2020 CDA Paper Abstraction Forms 2020 OBI DATA ABSTRACTION FORMS DEMOGRAPHICS Hospital Name: Patient Last Name: Patient First Name: Medical Record Number (MRN): Maternal Birthdate (MM/DD/YY): Postal Zip Hispanic Ethnicity: Code: Hispanic or Latino Not Hispanic or Latino Race (select all that apply): Unknown American Indian or Alaskan Native Asian Patient's Insurance Type: Black or African American Medicaid Self Pay/None Native Hawaiian or Other Pacific Islander Private Other: __________ White Unknown LABOR MANAGEMENT: Admission L&D Admission Date: L&D Admission Time: Provider admitting patient to Labor & Delivery (Last Name, First Name): Service/Practice patient admitted to: Admitting Nurse (Last name, First name): Certified Nurse Midwife Family Practice / Family Medicine Gravidity on admission: Parity on admission: Maternal Fetal Medicine Obstetrics Physician Maternal Height at admission: Maternal Weight at admission: Pre-pregnancy Weight: IN LBS LBS CM K G KG Did the patient receive prenatal care? If yes, date prenatal care Transfer of care from an intended home birth? started: Yes No Unable to determine Yes No LABOR MANAGEMENT: Maternal Comorbidities Present On Admission Pre-pregnancy diabetes (Type I or Type II Yes Was the patient using opioids during this Yes diabetes diagnosed prior to this pregnancy) No pregnancy? No Gestational diabetes (diagnosis in this pregnancy Yes What was the status of the patient's opioid use during this with or without medication tx) No pregnancy? (select all that apply): In treatment for opioid use disorder during pregnancy Pre-pregnancy chronic hypertension Yes No Ongoing opioid/heroin use disorder (without current tx) Opioid use for acute pain Gestational hypertension (PIH, preeclampsia, Yes eclampsia, HELLP syndrome) No Opioid use for chronic pain Previous diagnosis of asthma? Yes Unknown No Alcohol use during pregnancy? Yes Did the patient receive Medication Assisted Therapy (MAT) No for opioid use disorder during this pregnancy? Tobacco use before or during pregnancy? Yes No Yes, MAT with Buprenorphine (or Buprenorphine/Naloxone) If yes, did Mother quit smoking? Yes, MAT with Methadone Yes, MAT with Naltrexone Yes, before this pregnancy No MAT Yes, during this pregnancy Unknown No, did not stop smoking Unable to Determine LABOR MANAGEMENT: Planned Mode of Delivery Planned mode of delivery at time of admission: Planned labor for vaginal delivery Planned cesarean delivery What was the primary indication for the planned cesarean delivery? Abdominal cerclage Maternal Conditions, Other Abnormalities of the placenta – e.g. accreta, previa Maternal Request Active HSV Prior uterine surgery (myomectomy) Fetal Conditions, Other HIV with viral load >1000 LABOR MANAGEMENT: Admission with Labor for Planned Vaginal Birth Labor status at admission: Induction, membranes intact Spontaneous onset of labor, membranes intact Induction, pre-labor rupture of membranes Spontaneous onset of labor, membranes ruptured Select the primary indication for induction: If additional indications for induction, enter up to three: Cholestasis of pregnancy Cholestasis of pregnancy Chorioamnionitis Chorioamnionitis Diabetes Diabetes Elective (39+0 - 40+6 weeks, no medical indication) Elective (39+0+40+6 weeks, no medical indication) Fetal anomalies Fetal anomalies Fetal demise Fetal demise Fetal growth restriction Fetal growth restriction Fetal macrosomia Fetal macrosomia Fetal indication, Other, Specify: Fetal indication, Other, Specify: Hypertensive disorder of pregnancy (preeclampsia, Hypertensive disorder of pregnancy (preeclampsia, gestational hypertension) gestational hypertension) Isoimmunization Isoimmunization Non-reassuring fetal testing, decreased fetal Non-reassuring fetal testing, decreased fetal, non- movement, non-reassuring fetal heart tones reassuring fetal heart tones Obesity Obesity Oligohydramnios Oligohydramnios Placental abruption Placental abruption Postdate (greater than or equal to 41 weeks) Postdate (greater than or equal to 41 weeks) PROM PROM Maternal indication, Other, Specify: Maternal indication, Other, Specify: None Were cervical ripening methods undertaken prior to If yes, select all methods that were used prior to admission: admission (i.e. outpatient clinic)? Transcervical catheter (Foley balloon, Cook catheter, etc.) Yes Prostaglandin agent No Page 2 of 9 Select the ripening/induction intervention(s) used any time during admission: Amniotomy Misoprostol Transcervical catheter with Misoprostol Cervidil Oxytocin Transcervical catheter with Oxytocin Membrane stripping Transcervical catheter Unable to determine Within the 72 hours prior to admission, were there any How many visits in Hours between discharge of last triage unscheduled triage/ED not leading to an admission? those 72 hours? visit and delivery admission: Yes No Was a cervical exam done at the time Yes Cervical dilation at admission: of admission? No . cm If cervical dilation less than 4, what was the reason for early admission for spontaneous labor? (Select all that apply): Abnormal FHTs No prenatal or late prenatal care Difficulty with coping/pain management Shared decision-making pt. request for admission Distance from home is too far Time to provide GBS preventative therapy Hypertension Transportation challenges Maternal fatigue Other, Specify: ______________________ Membranes ruptured Cervical effacement at admission: % Fetal station at admission: Group B Strep status during this pregnancy: Fetal monitoring type ordered at admission (select all that apply): Positive Continuous Electronic Fetal Monitoring (CEFM) Negative Intermittent Auscultation (IA) Not documented Not documented Rupture of membranes: Rupture of membranes date and time: Cervical dilation at rupture of membranes: Amniotomy . cm Spontaneous (any time during labor) Unable to determine Not documented Was Oxytocin used at any time prior Date and time Oxytocin started: Cervical dilation when decision to to delivery? initiate Oxytocin: Yes . cm No Fetal monitoring type used for Active Labor (≥ 6cm) Nurse supporting active labor (≥ 6cm) (Last name, First name): (select all that apply): Continuous Electronic Fetal Monitoring (CEFM) Intermittent Auscultation (IA) Not documented Provider supporting active labor (≥ 6cm): Dx of Clinical Chorioamnionitis (Triple Yes I) during labor? No Attempted forceps delivery? Yes If yes, was forceps attempt successful? Successful No Unsuccessful Attempted vacuum delivery? Yes If yes, was vacuum attempt successful? Successful No Unsuccessful Page 3 of 9 Method(s) to assess pain/discomfort/ Non-pharmacologic pain management (select Pharmacologic pain management coping during labor (select all that all that apply): (select all that apply): apply): Aroma Therapy Comfort/Coping scale Birthing balls / peanut balls IV narcotics Pain scale (faces, numeric, etc.) Massage Nitrous oxide Other, specify: Tens Unit Oral narcotics Walking Pudendal block None Water / Shower / Tub Other, specify: Other, specify: None None Did the patient receive regional anesthetic? Yes If yes, type: Epidural No Combined spinal/epidural Unable to determine Was there an order for patient-controlled epidural When in labor was the epidural placed? analgesia? 1st stage < 6cm 2nd stage Yes No Unable to determine 1st stage ≥ 6cm Unable to determine Shared decision-making methods reviewed upon admission or during labor (select all that apply): Document or tool scanned into chart (e.g. Birth plan, Preferred plans documented by nursing labor partnership) Not documented/Unable to determine CNM/Physician statement in H&P or admission note Was a doula present? Was a support person (family, friend, partner) present? Yes No/Not documented Yes No Not documented DELIVERY Date/Time cervix completely dilated: Date/Time pushing started: Provider attending birth: Which service/practice delivered this patient? Certified Nurse Midwife Nurse attending birth (Last name, First name): Maternal Fetal Medicine Family Practice / Family Medicine Actual mode of delivery: Obstetrics Physicians Spontaneous (unassisted) vaginal Was the delivery from an OP (Occiput Yes Forceps vaginal Posterior) fetal position? No Vacuum vaginal Was an episiotomy performed? Yes Cesarean during labor No Planned cesarean delivery admitted in labor or after spontaneous rupture of membranes Did the patient Yes experience a 3rd degree Planned cesarean section without labor perineal laceration? No Did the patient Yes experience a 4th degree perineal laceration? No Page 4 of 9 CESAREAN DELIVERY Cervical Dilation, exam closest to Cesarean Delivery: Cervical Exam closest to Cesarean Delivery Date/Time: _______. _______ cm Primary indication for Cesarean Delivery: *If arrest of dilation <6cm: Failed induction of labor (< 6cm) Were moderate or strong contractions present for > 12 hours without cervical change? Latent phase arrest of dilation (< 6cm)* Yes No Unable to determine Active phase arrest of dilation (≥ 6cm)** Arrest of descent – First stage*** Was an intrauterine pressure catheter (IUPC) used? Arrest of descent – Second stage*** Yes No Unable to determine Abnormal or indeterminate fetal heart rate tracing (Fetal Was there documentation of ≥ 200 Montevideo units (MVU) intolerance of labor, or non-reassuring fetal heart for ≥ 12 hours without cervical change? tracings) Yes No Unable to determine Malpresentation (any noncephalic presentation) **If arrest of dilation ≥ 6cm Macrosomia – Suspected based on ultrasound or clinical estimate Were there adequate uterine contractions (e.g. moderate or strong on palpation for ≥ 4 hours) without improvement in
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