Medical Record Abstraction Form

 

 

ID _________

http://www.medical-record.blogspot.com/

Instructions: Please review the infant and maternal medical records

Please review the maternal medical record for questions 1-15:

1.    What is the mother’s month and year of birth?   ___/_________

2.    What is the ethnicity of the mother?

 Hispanic or Latino                     Not Hispanic or Latino        unknown

3.    What is the race of the mother? Please check all that apply.

 White  African American   Asian   American Indian or Alaska

Native  Native Hawaiian or Other Pacific Islander  Other or unknown

4.    Mother’s Insurance Status?

 Private  Medicaid  Other or Unknown

5.    Please indicate admission date ___/___/_____  and time ___:___ am/pm

 

Prenatal Care

6.    Was there a prenatal HBsAg (hepatitis B surface antigen) test performed prior to admission?

 Yes              No                         

7.    What was the prenatal HBsAg test date? ___/___/_____   Not documented

8.    What was the prenatal HBsAg test result?

 Positive  Negative  Not documented     

9.    How was HBsAg status of mother documented?

 Copy of laboratory report

 Clinician transcription of information into medical record from other source

 Other, describe: _____________________________________

10.  Was there an HIV test performed prior to admission?

 Yes              No                                      

11.  What was the prenatal HIV test date? ____/___/____  Not documented

Consider adding additional questions on syphilis, GBS, etc.

Admission to Labor and Delivery

12.  Was there an HBsAg test performed during the hospital stay?

 Yes              No                                                 

13.  What was the result of the HBsAg test performed during the hospital stay?

 Positive       Negative     Not documented

14.  Was there an HIV test performed during the hospital stay?

 Yes              No             

15.  Type of attending provider

 Obstetrician  Family practitioner  Other or unknown


Please review neonatal medical record for Questions 16-29:

16.  Please indicate infant’s date of delivery ___/___/_____  and time of delivery ___:___ am/pm

17.  Did the infant weigh <2,000 grams at birth?

             Yes                          No                         

18.  Is there a recorded maternal HIV test result?

 Yes                          No             

19.  Is there a recorded maternal HBsAg test result?

 Yes                          No                         

20.  What was the maternal HBsAg test result?

 Positive                   Negative

21.  Was HBIG (hepatitis B immune globulin) given to the infant?

 Yes; date ___/___/_____   Time ___:___ am/pm

 No

22.  Was infant HBIG administered as a result of hospital pre-printed admission orders*?

 Yes                                No                         

23.  If there were no hospital pre-printed admission orders*, was infant HBIG administered as a result of a specific physician order?

 Yes                                No                         

24.  Was hepatitis B vaccine given to the infant?

 Yes                                No             

25.  Please indicate date of hepatitis B vaccine  ___/___/_____  and time of  administration ___:___ am/pm

26.  Was hepatitis B vaccine administered as a result of hospital pre-printed admission orders*?

 Yes                                No                         

27.  If there were no hospital pre-printed admission orders*, was hepatitis B vaccine administered as a result of a specific physician order?

 Yes                                No                         

28.  Was there any specific order in the neonatal medical record not to vaccinate against hepatitis B virus?

 Yes                                No; end survey     

29.  If there was an order not to vaccinate, what was documented as the reason for not vaccinating? Please check all that apply.

 Infant was <2,000 grams at birth

 Infant was not medically stable

 Mother was HBsAg negative

 Guardian refused

 No reason documented

 Other reason; please specify below:

Thank you for your participation!

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