Nova Scotia Atlee Perinatal Database Coding Manual 15th Edition (Version 15.0.0) April 2011 TABLE OF CONTENTS LISTINGS OF HOSPITALS 11 ADMISSION INFORMATION 16 DELIVERED ADMISSION 26 Routine Information – Delivered Admission 26 Routine Information – Labour 57 Routine Information – Infant 77 UNDELIVERED ADMISSION 94 Routine information – undelivered 94 POSTPARTUM ADMISSIONS 104 Routine Information – Postpartum Admission 104 NEONATAL ADMISSIONS 112 Routine Information – Neonatal Admissions 112 ADULT RCP CODES 124 INFANT RCP CODES 143 INDEX OF MATERNAL DISEASES AND PROCEDURES 179 INDEX OF NEONATAL DISEASES AND PROCEDURES 195 1 INDEX FOR ADMISSION INFORMATION Admission date .............................................................................................................................. 17 Admission time .............................................................................................................................. 17 Admission process status ............................................................................................................... 25 Admission type .............................................................................................................................. 17 A/S/D number ................................................................................................................................ 18 Birth date ....................................................................................................................................... 18 Care provider attending ................................................................................................................. 22 City/town ...................................................................................................................................... 23 Contact hospital ............................................................................................................................ 16 Discharge date ............................................................................................................................... 16 Discharge time .............................................................................................................................. 16 Given name(s) ............................................................................................................................... 17 Health card number ....................................................................................................................... 18 Mail address .................................................................................................................................. 23 Marital status .................................................................................................................................. 22 Municipal code for residence ........................................................................................................ 19 Postal code .................................................................................................................................... 23 Previous surname .......................................................................................................................... 17 Province ........................................................................................................................................ 24 Sex ................................................................................................................................................ 22 Street address ................................................................................................................................ 23 Surname ........................................................................................................................................ 17 Unit number .................................................................................................................................. 16 2 INDEX FOR ROUTINE INFORMATION – DELIVERED ADMISSION Abdominal circumference measurements ..................................................................................... 44 Abdominal circumference gestational age .................................................................................... 46 Abortions ...................................................................................................................................... 29 Admitted from ............................................................................................................................... 27 Analgesia during labour ................................................................................................................ 52 Antibiotic therapy ......................................................................................................................... 53 Antibiotic date ............................................................................................................................... 55 Antibiotic time .............................................................................................................................. 56 Attendance at prenatal classes ....................................................................................................... 39 Autopsy (maternal) ....................................................................................................................... 50 Biparietal diameter measurement .................................................................................................. 44 Biparietal diameter gestational age ............................................................................................... 46 Crown/rump length measurements ............................................................................................... 43 Crown/rump length gestational age .............................................................................................. 45 Date of first ultrasound ................................................................................................................. 42 Date of last normal menstrual period ............................................................................................ 28 Delivery hospital ........................................................................................................................... 26 Education ...................................................................................................................................... 36 Femur length measurement ............................................................................................................ 45 Femur length gestational age ......................................................................................................... 47 Fetus number .................................................................................................................................. 42 Fetal Surveillance Methods ............................................................................................................ 68 Gravida .......................................................................................................................................... 28 Head circumference measurements .............................................................................................. 44 Head circumference gestational age ............................................................................................. 46 Intent to breast feed ....................................................................................................................... 37 Initial breast contact ...................................................................................................................... 68 Maternal height ............................................................................................................................. 38 Maternal screening test(s) ............................................................................................................. 48 Maternal ultrasound ...................................................................................................................... 42 Maternal steroid therapy ................................................................................................................ 51 Maternal primary cause of death ................................................................................................... 50 3 INDEX FOR ROUTINE INFORMATION – DELIVERED ADMISSION Number of fetuses ......................................................................................................................... 41 Number of abortions ..................................................................................................................... 29 Number of previous C-sections...................................................................................................... 31 Number of previous fetal deaths .................................................................................................... 30 Number of previous low birth weight infants ................................................................................ 32 Number of previous neonatal deaths ............................................................................................. 30 Number of previous pre-term deliveries ....................................................................................... 31 Number of previous postpartum hemorrhage ..............................................................................