New York City Department of Health and Mental Hygiene Bureau of Vital Statistics Facility Worksheet for Newborn Registration To be completed by Facility Staff • This worksheet contains items to be completed by the facility staff. Items in GREEN will be provided by the Mother/Parent and should be entered into the Electronic Birth Registration System (EBRS) from the Mother/ Parent’s Worksheet. If ALL items on a specific EBRS Screen are from the Mother/Parent’s worksheet, instructions will indicate: See MOTHER/PARENT’S WORKSHEET for all items on this screen. • The items on the Mother/Parent’s Worksheet and this Facility Worksheet are listed in order of the EBRS data entry screens. Please follow the instructions below to obtain and enter accurate data into EBRS. For Facility Birth Registration Tracking Purposes Mother/Parent’s Name: Number delivered this pregnancy If more than one, birth order of this child SCREEN: START A NEW CASE Child’s Last Name Date of Once you have completed the form below, you Child’s (found on Monther’s Worksheet) ___ ___ / ___ ___ / ___ ___ ___ ___ Birth will be ready to Start a New Case in EBRS. Month Day Year You must have the following information to Child’s Sex Female Mother/Parent’s Medical Child’s Medical Male Record Number Record Number start a new case: Undetermined SCREEN: CHILD Name of Child Date of Child’s Birth Time of Child’s Social Security number for Child? Safe Haven / Foundling Baby AM No military (Last name (and any other name) is automatically filled from Start New Case Screen) (Automatically filled from Birth ___ ___ : ___ ___ PM time accepted Yes No See Mother’s Worksheet Start New Case Screen) (found on Monther’s Worksheet) Defaults to No 12 PM is noon; 12 AM is midnight SCREENS: MOTHER/PARENT, MOTHER/PARENT ADDRESS, MOTHER/PARENT ATTRIBUTES See Mother/Parent’s Worksheet for all items on these screens SCREEN: MOTHER/PARENT HEALTH See Mother/Parent’s Worksheet Mother/Parent Weight at Delivery Illicit and other drugs Yes If yes, Heroin Methamphetamine Tranquilizers used during this pregnancy? Check ALL that apply: Cocaine Marijuana Anticonvulsants for most items on this screen; No Methadone Sedatives None of the above (Other illicit ____ ____ ____ lbs. 2 additional items are listed here. drug(s) were used—not listed above.) SCREEN: PATERNITY Are you entering the Father/Parent’s Yes, Married Yes, Acknowledgment of Paternity (AOP) No information? (See link to print AOP with corresponding tracking number) SCREENS: FATHER/PARENT, FATHER/PARENT ATTRIBUTES (See Father/Parent’s section of Mother/Parent’s Worksheet for all items on this screen) VR-204 (12/09) SCREEN: PLACE OF BIRTH VR-204 (12/09) Type of Ⅺ Hospital (if logged in as a hospital site, your facility will be automatically filled in) Home Delivery Planned (please complete address of birth below) Place of Ⅺ Manhattan Place Freestanding Birthing Center (if logged in as a birthing center, your facility will be automatically filled in) Home Delivery Unplanned (please complete address of birth below) Birth Bronx (of birth): Clinic/Doctor’s Office (please complete name and address below) Home Delivery Unknown if Planned (please complete address of birth below) (NYC borough): Brooklyn Queens Other (Specify) _________________________________________________________________________ Staten Island Name of hospital or other facility; if not facility, street address (If logged in as hospital or birthing center, the facility name and address will be filled automatically) Street Address City State ZIP Code SCREEN: PRENATAL Mother/Parent Medical Record Number If Medicaid, enter Medicaid Number: Primary Ⅺ Medicaid/Family Health Plus CHAMPUS/TRICARE Date last normal menses began Payer Private Insurance Other Self-pay (Automatically filled in from Start New Case screen) (Check ONE): Other Govt/CHPlusB Unknown ___ ___ / ___ ___ / ___ ___ ___ ___ Month Day Year Is the mother/parent enrolled in an HMO or other managed care plan? Yes No Ⅺ No Date of first prenatal care visit Date of last prenatal care visit Total number of prenatal care Primary prenatal care MD/DO No provider prenatal visits for this pregnancy provider type C(N)M/NP/PA/Other Midwife No information care (Check ONE): Clinic Other ___ ___ / ___ ___ / ___ ___ ___ ___ ___ ___ / ___ ___ / ___ ___ ___ ___ ___ ___ Month Day Year Month Day Year TOTAL number of previous live births: (a + b = ) _______ Date of first live birth Date of last live birth Those born alive may have been preterm, low birth weight or both. (Indicate only live births resulting from PRIOR PREGNANCIES): a) Number born alive and now living _______ ___ ___ / ___ ___ ___ ___ ___ ___ / ___ ___ ___ ___ Number preterm (<37 wks): _________ b) Number born alive and now dead _______ Month Year Month Year Number low birth weight (<2500 grams or 5 lbs. 8 oz.): _______ TOTAL number of other pregnancy outcomes: ( c + d + e = ) _______ Date of last other pregnancy outcome (spontaneous or induced termination): A spontaneous termination can be called a miscarriage, missed abortion, or spontaneous abortion c) Number of spontaneous terminations of pregnancy less than 20 weeks: _______ —usually when < 20 weeks and a stillbirth or fetal death when 20 weeks or more. d) Number of spontaneous terminations of pregnancy 20 weeks or more: _______ An induced termination can be called an abortion. ___ ___ / ___ ___ ___ ___ e) Number of induced terminations of pregnancy: _______ Month Year SCREEN: PREGNANCY FACTORS Risk factors in this pregnancy (Check ALL that apply): Ⅺ Pre-pregnancy diabetes Ⅺ Other serious chronic illness Ⅺ Hemoglobinopathy Ⅺ Prelabor referral for high risk care Infertility treatment: Fertility drugs, artificial/intrauterine insemination Ⅺ Gestational diabetes Ⅺ Anemia (Hct.<30/Hgb.<10) Ⅺ Abruptio placenta Ⅺ Other vaginal bleeding Infertility treatment: Assisted reproductive technology (e.g. IVF, GIFT) Ⅺ Pre-pregnancy hypertension Ⅺ Asthma/Acute or chronic lung disease Ⅺ Eclampsia Ⅺ Previous cesarean section Number of embryos implanted (if applicable) ___________ Ⅺ Gestational hypertension Ⅺ Rh sensitization Ⅺ Other previous poor Number previous cesarean sections: Ⅺ Fetal reduction Ⅺ Cardiac disease: Structural defect Ⅺ Polyhydramnios pregnancy outcome Ⅺ None of the above ___________ Ⅺ Cardiac disease: Functional defect Ⅺ Oligohydramnios Infections present and/or treated during (this) pregnancy (Check ALL that apply): Obstetric procedures (Check ALL that apply): If woman was 35 or over, was fetal genetic testing offered? Gonorrhea Hepatitis C Cervical cerclage Fetal genetic testing Yes Syphilis Tuberculosis Tocolysis None of the above No, too late Herpes simplex (HSV) Rubella External cephalic version: Successful No, other reason Chlamydia Bacterial vaginosis External cephalic version: Failed Hepatitis B None of the above SCREEN: LABOR Onset of labor (Check ALL that apply): Characteristics of labor and delivery (Check ALL that apply): Prolonged rupture of membranes (12 hours or more) Induction of labor – AROM Other excessive bleeding Febrile (>100.4F or 38C) External electronic fetal monitor Premature rupture of membranes (prior to labor) Induction of labor – Medicinal Steroids Meconium staining Internal electronic fetal monitor Precipitous labor (less than 3 hours) Augmentation of labor Antibiotics Fetal intolerance None of the above Prolonged labor (20 hours or more) Placenta previa Chorioamnionitis None of the above SCREEN: DELIVERY VR-204 (12/09) Was delivery with forceps Indication for forceps Was delivery with vacuum extraction Indications for vacuum Fetal presentation at birth FINAL route and method of delivery If cesarean, was trial attempted but unsuccessful? (Check ALL that apply): attempted but unsuccessful? (Check ALL that apply): (Check ONE): (Check ONE): of labor attempted? Attempted and successful Failure to progress Attempted and successful Failure to progress Cephalic Vaginal/spontaneous Yes Attempted but unsuccessful Fetus at risk Attempted but unsuccessful Fetus at risk Breech Vaginal/forceps No Forceps were not used Other Vacuum extraction was not used Other Other Vaginal/vacuum Unknown Unknown Cesarean Indications for C-section (Check ALL that apply): Other procedures performed at delivery (Check ALL that apply): Anesthesia (Check ALL that apply): Ⅺ Failure to progress Ⅺ Maternal condition, Ⅺ Refused VBAC Episiotomy and repair Epidural General intravenous Paracervical Local Ⅺ Malpresentation not pregnancy related Ⅺ Elective Sterilization General inhalation Spinal Pudendal None of the above Ⅺ Previous C-section Ⅺ Maternal condition, Ⅺ Other Repair of lacerations Ⅺ Fetus at risk/NFS pregnancy related Unknown None of the above Complications from any of the above? Yes No Maternal morbidity (Did any of the following complications occur?) (Check ALL that apply): If birth occurred in hospital, was mother/parent transferred in before giving birth? Infant transferred (to another hospital)? Ⅺ Maternal transfusion Ⅺ Unplanned operating room procedure Yes No Within 24 hours of delivery Not transferred Ⅺ Perineal laceration following delivery After 24 hours of delivery If yes, name of facility transferred from: (3rd or 4th degree) Ⅺ Hemorrhage If transferred, name of facility transferred to: Ⅺ Ruptured uterus Ⅺ Postpartum transfer to a higher level of care Ⅺ Unplanned hysterectomy Ⅺ None of the above Ⅺ Admit to ICU ____________________________________________ ____________________________________________