Nova Scotia Atlee Perinatal Database Coding Manual 13th Edition (Version 13.0.0) April 2009 TABLE OF CONTENTS LISTING OF HOSPITALS ...................................................12 ADMISSION INFORMATION ...............................................18 DELIVERED ADMISSIONS Routine Information - Delivered .......................................28 Routine Information - Labour .........................................56 Routine Information - Infant ..........................................75 UNDELIVERED ADMISSIONS Routine Information - Undelivered .....................................94 POSTPARTUM ADMISSIONS Routine Information - Postpartum ....................................104 NEONATAL ADMISSIONS Routine Information - Neonatal ......................................112 ADULT RCP CODES ....................................................124 INFANT RCP CODES ....................................................140 INDEX MATERNAL DISEASES AND PROCEDURES .............................171 INDEX NEONATAL DISEASES AND PROCEDURES ............................187 -1- INDEX FOR ADMISSION INFORMATION Admission date ..........................................................18 Admission time ..........................................................19 Admission Process Status .................................................27 Admission type ..........................................................19 A/S/D number ...........................................................20 Birth date ..............................................................20 Care provider attending ....................................................25 City/Town ..............................................................25 Contact hospital .........................................................18 Discharge date ..........................................................18 Discharge time ..........................................................18 Given name(s) ..........................................................19 Health card number ......................................................20 Mail address ............................................................25 Marital status ............................................................24 Municipal code for residence ................................................21 Postal code .............................................................26 Previous surname ........................................................19 Province ...............................................................26 Sex .................................................................. 25 Street address ..........................................................25 Surname ...............................................................19 Unit number ............................................................18 -2- INDEX FOR ROUTINE INFORMATION - DELIVERED ADMISSION Abdominal circumference measurement .........................................46 Abdominal circumference gestational age ........................................48 Abortions ................................................................31 Admitted from ............................................................29 Analgesia during labour ....................................................53 Antibiotic therapy .........................................................54 Antibiotic date ............................................................54 Antibiotic time ............................................................55 Attendance at prenatal classes ...............................................41 Autopsy (maternal) ........................................................52 Biparietal diameter measurement ..............................................46 Biparietal diameter gestational age .............................................48 Crown/rump length measurement ..............................................45 Crown/rump length gestational age .............................................47 Date of first ultrasound .....................................................44 Date of last normal menstrual period ..........................................30 Delivery hospital ..........................................................28 Discharge date/time .......................................................51 Discharge to .............................................................51 Early Breast Contact .......................................................83 Education ...............................................................38 Femur length measurement ..................................................47 Femur length gestational age .................................................49 Fetus number ............................................................43 Gravida .................................................................30 Head circumference measurements ............................................46 Head circumference gestational age ............................................48 Intent to breast feed .......................................................39 Maternal height ...........................................................41 Maternal Screening Test(s) ..................................................50 Maternal ultrasound .......................................................44 Maternal Steroid Therapy ....................................................52 Maternal Primary Cause of Death ..............................................51 -3- Number of fetuses ........................................................44 Number of abortions ........................................................31 Number of previous c-sections ...............................................33 Number of previous fetal deaths ..............................................32 Number of previous low birth weight infants .....................................34 Number of previous neonatal deaths ..........................................32 Number of previous overweight infants .........................................34 Number of previous pre-term deliveries ........................................33 Number of previous postpartum hemorrhage ....................................33 Para ....................................................................31 Pre-conceptional folate intake ................................................30 Prenatal record on chart at time of coding .......................................29 Pre-pregnancy smoking ....................................................35 Pre-pregnancy weight ......................................................40 Present weight ...........................................................43 Process status ...........................................................55 Race/ Ethnicity ...........................................................39 Route of administration for analgesia ..........................................53 Smoking at first prenatal visit ................................................36 Smoking at time of delivery ..................................................42 Smoking at 20 weeks ......................................................37 -4- INDEX FOR ROUTINE INFORMATION - LABOUR APGAR score ............................................................72 Birth order ...............................................................56 Birth weight ..............................................................71 Care provider attending delivery ...............................................73 Date of medical augmentation ...............................................64 Date of rupture of membranes ...............................................56 Date/time of admission to LDR ...............................................63 Date/time of 4 centimeters dilatation ...........................................66 Date/time of second stage ..................................................67 Dilatation at c-section ......................................................70 Dilatation at medical augmentation ............................................65 Dilatation on admission to LDR ...............................................64 Episiotomy ..............................................................71 Indication for induction .....................................................60 Induction of labour - methods and agents .......................................61 Induction of labour - place ...................................................61 Labour ..................................................................59 Meconium staining ........................................................58 Medical augmentation ......................................................64 Method of delivery .........................................................69 Mode of delivery ..........................................................68 Oxytocin date/time ........................................................62 Position at delivery ........................................................70 Primary indication for c-section ...............................................73 Time of admission to LDR ...................................................63 Time of medical augmentation ...............................................64 Time of rupture of membranes ...............................................57 Type of rupture of membranes ...............................................58 -5- INDEX FOR ROUTINE INFORMATION - INFANT A/S/D number ............................................................78