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|Requirement ID:||Req-95: Link maternal and birth data to child health record||Req-2001: Link maternal and birth data to child health record|
|Release Package:||2013 Format||2015 Priority List|
|Title:||Link maternal and birth data to child health record||Link maternal and birth data to child health record|
|Description:||The system SHALL provide for the linking or recording of maternal and birth data to the child health record. Examples: maternal social history, maternal prenatal results, and gravida/para (GP).||The system shall import birth information from an electronic newborn discharge summary as discrete data elements.
All other requirements, such as gestation age, can be incorporated into a birth data elements list.
|Topic Area(s):||Birth Information||Birth Information|
|Provenance:||IH Gap Analysis - SME||Not Applicable|
|Requirement Type:||Normative Statements||Normative Statement|
|See Also:||DC.1.1.3, CH13.03, FN01.01|
|Implementation Notes:||Birth information is an essential and unique requirement of child’s EHR and is a collection of data elements about the child at birth, many of which are taken from the mother’s prenatal and delivery records. Birth information is static because it is obtained from external sources (the mother’s records and the birth facility), refers to a specific point in time, and needs to be accessed at most well child visits during the first year of life and at other times as needed. It should be used at more than just the first newborn visit. In addition, the system should have the ability to edit the information at any time, if it is found to contain confirmed errors. LOINC codes that have been developed for newborn screening and for ACOG prenatal and delivery records should be used to define the data elements and the appropriate answer lists or formats. Any EHR that imports discrete data from HL7 Clinical Document Architecture (CDA) level 3 electronic documents such as the Continuity of Care Record (CCR or c-CCR) should be able to easily add functionality for importing future electronic newborn discharge summaries— providing that data elements in the CDA are identified by LOINC codes and can be mapped to data elements in the EHR, which are also identified by the same LOINC codes. Therefore, preserving LOINC codes is important to identify data elements inside an EHR and and not just in external messages, for data that are imported (such as data from the mother’s EHR), and to re-export those same codes in future messages or documents. Importing birth data from electronic messages or documents is the preferred method for capturing birth data but is not required to meet this requirement for a child EHR. Neonatal physical exam, including symmetry (as symmetrical or nonsymmetrical growth retardation), was not included because it is narrative text and not discrete data. It will be available in a child’s EHR as age-specific physical examination in the hospital or initial newborn visits and any significant findings should be included in the problems list (such as a heart murmur or hip click). Birth order for familial rank (not birth order for multiple births such as twins) was not included because it is better to use a family history pedigree, and birth order (oldest to youngest) will change over time in modern blended families. Maternal demographic data was not included and should be available as part of registration or family history data, but maternal age at time of birth is part of the core data elements list. *Birth Information Data Elements* There are several possible sources of a birth information data elements list. The initial list included below is based on requirements from the child EHR. Additional lists that should be consider include the ACOG prenatal, delivery, and initial newborn record as well as information required for ordering and reporting newborn screening results (available at NLM newborn screening codes Web site). *Core Birth Data Elements From Child EHR Requirements* • Precise birth date and time storage—to the minute if required by the scope of practice • Birth weight in kg—to 3 decimal places • Gestational age at birth in weeks and days • Basis for gestational age—last menstrual period (LMP), ultrasound, maternal report, Dubowitz scoring, Ballard Exam, or a future method • Singleton, twin, or multiple gestation • Birth order if not a singleton • Mechanism of delivery—Spontaneous Vaginal Delivery (SVD), Assisted Vaginal Delivery, Precipitous Vaginal Delivery, Emergent Cesarean section, Elective Cesarean section • Delivery assistance—No Assistance, Forceps, Mid Forceps, High Forceps, or Vacuum Extraction • 1 minute Apgar • 5 minute Apgar • 10 minute Apgar • Maternal age • Maternal GPAL—Gravida/Para/Abortus Status/Living Children • Maternal blood type • Maternal antibody status—Combs test • Maternal rubella status—Immune, Non-Immune, Pending, or Unknown • Maternal sickle cell status—HbSS, HbSC, HbS-Thal, Negative, Pending, or Unknown • Maternal hepatitis B status—Positive, Negative, Unknown, or Pending • Maternal VDRL status—Positive, Negative, Unknown, or Pending • Maternal HIV status—Positive, Negative, Unknown, or Pending • Maternal GBS status—Positive, Negative, Unknown, or Pending • Maternal gonorrhea status—Positive, Negative, Unknown, or Pending • Maternal chlamydia status—Positive, Negative, Unknown, or Pending • Prenatal care provider information—name and practice affiliation • Alcohol use during pregnancy—Positive, Negative, or Unknown • Average amount of alcohol used per day • Tobacco use during pregnancy—Positive, Negative, or Unknown • Average amount of tobacco used per day • THC use during pregnancy—Positive, Negative, or Unknown • Average amount of THC used per day • Cocaine use during pregnancy—Negative, or Unknown, as well as the average dollar amount of cocaine used per day • Narcotics use during pregnancy—Positive, Negative, or Unknown • Type of narcotics used • Average dollar amount of narcotics used per day • Amphetamine use during pregnancy—Positive, Negative, or Unknown • Average dollar amount of amphetamine used per day • Illicit drug use during pregnancy—Positive, Negative, or Unknown • Illicit drug use during pregnancy—name, dose, and frequency of use • Maternal drug screening results—drug tested and results Positive, Negative, Pending, or Unknown *Additional birth data elements not included because they are used in the inpatient setting to document management of special care infants (not core requirements)* • Betamethasone prior to delivery—date and time • Perinatal magnesium sulfate administration • Tocolytics administration • Perinatal antibiotic administration—type, date, time, and number of antibiotic doses administered before and during delivery • Additional prescription and nonprescription medications and supplements—name, dose, frequency, and route • Labor—spontaneous or induced • Labor onset—spontaneous or induced • Rupture of membranes details—spontaneous (SROM), artificial (AROM), premature (PROM), or preterm, premature (PPROM) • Record color of amniotic fluid—clear, cloudy, bloody, light meconium, moderate meconium, thick meconium, terminal meconium • 1-minute Apgar details—HR 0,1,2 | RR 0,1,2 | Tone 0,1,2 | Reflex 0,1,2 | Color 0,1,2 | • 5-minute Apgar details—HR 0,1,2 | RR 0,1,2 | Tone 0,1,2 | Reflex 0,1,2 | Color 0,1,2 | 10 minute Apgar • 10-minute Apgar details—HR 0,1,2 | RR 0,1,2 | Tone 0,1,2 | Reflex 0,1,2 | Color 0,1,2 | • Continuing Apgar scores—every 5 minutes after 10 minutes if the total score is less than 5 • Continuing Apgar scores details—HR 0,1,2 | RR 0,1,2 | Tone 0,1,2 | Reflex 0,1,2 | Color 0,1,2 | and Total 0-10 • Umbilical cord blood gas—umbilical cord blood gas results if available • Oxygen saturation in delivery room—percutaneous oxygen saturation measurements in the delivery room • Clinical staff at delivery—pediatrician(s), nurse(s), and respiratory therapist(s) present at delivery • Respiratory support in neonatal resuscitation—Blow-by O2, Nasal Cannula O2, Bag/Mask Ventilation, CPAP, or Endotracheal Intubation • FiO2 administration in neonatal resuscitation • Chest compression duration in neonatal resuscitation • Epinephrine in neonatal resuscitation—dose, route, and frequency of epinephrine used during resuscitation • Normal saline in neonatal resuscitation—dose, route, and frequency of normal saline solution used during resuscitation • Narcan in neonatal resuscitation—dose, route, and frequency of calcium chloride used during resuscitation • Na-bicarbonate in neonatal resuscitation—dose, route, and frequency of sodium bicarbonate used during resuscitation • Blood use in neonatal resuscitation—dose, route, and frequency of blood products used during resuscitation • Delivery room procedures • Surfactant administration in delivery room *Birth Data Fields Newborn Screening Panel LOINC 54089-8* 57717-1 Newborn screen card data panel 57716-3 State printed on filter paper card [Identifier] in NBS card 8339-4 Birthweight g 58229-6 Body weight Measured—when specimen taken g 57715-5 Time of birth 57722-1 Birth plurality of Pregnancy 57714-8 Obstetric estimation of gestational age wk 57713-0 Infant NICU factors that affect newborn screening interpretation 67703-9 Other infant NICU factors that affect newborn screening interpretation Narrative 67706-2 Maternal factors that affect newborn screening interpretation 67707-0 Other maternal factors that affect newborn screening interpretation Narrative 67704-7 Feeding types 67705-4 Other feeding types Narrative 62317-3 Date of last blood product transfusion 58232-0 Hearing loss risk indicators [Identifier] 57712-2 Mother's education 57723-9 Unique bar code number of Current sample 57711-4 Unique bar code number of Initial sample 62329-8 Birth hospital facility ID [Identifier] in Facility 62330-6 Birth hospital facility name 62331-4 Birth hospital facility address 62332-2 Birth hospital facility phone number in Facility|