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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
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?
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?
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
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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