1) County of Birth: _ Miami-Dade Broward 2) City of Birth: Miami Miami Beach Homestead Forth Lauderdale _ 3) Reporting hospital: _ Baptist Miami Children's Jackson Memorial South Miami Hospital 4) State number for hospital:
1) Mother's name: 2) Age (years): 3) SSN: 4) Mother's Hospital # : 5) Hospital of Delivery: 6) Non-Hospital Delivery? No Yes 7) Maternal transfer? No Yes From on mm/dd/yy 8) Antenatal Care? Yes No 9) Antenatal Steroids? No Yes 10) C/section? No Yes 11) Gravida: Para (Term:/ Preterm:/ Abortions:/ Living: 12) Healthcare Funding: Insurance HMO Medicaid None
1) Name: 2) Hospital # : 3) Date of Birth: mm/dd/yy 4) Date of Admission: mm/dd/yy 5) Birth Weight: gm 6) Best EGA: weeks by LMP Ultrasound Exam 7) Apgar Score: 1-min, 5-min 8) Gender: Male Female 9) Race : Black White Oriental Other 10) Hispanic? Yes No 11) Disposition: death discharge transfer to Level 1 transfer to level 2 transfer to level 3 on mm/dd/yy. 12) Weight at Disposition: gm 13) Healthcare Funding: Insurance HMO Medicaid None
1) Diagnoses : 2) Procedures:
1) ICH Yes No Maximum Grade: 1 2 3 4 (Papile Classification) 2) Cystic PVL? Yes No 3) ROP Stage : I II III IV (Maximum at discharge, by International Classification). Treatment: None Laser Cryo Laser & Cryo 4) NEC : Yes No (Pneumatosis intestinalis or path diagnosis) Surgery for NEC? Yes No 5) CLD : Yes No ( defined as oxygen requirement at 36 weeks corrected age = EGA + PNA) Final Date off mechanical ventilation: mm/dd/yy ; (excludes temporary need during surgical procedures) Final Date off oxygen therapy: mm/dd/yy ; (excludes temporary need during surgical procedures) Discharged home on oxygen? No Yes 6) Sepsis: (bacterial, viral or fungal - based on positive blood and/or CSF cultures) Early (< 72 hrs of age): No Yes Organism: Late (> 72 hrs of age): No Yes Organism(s):