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Perinatal Database Registry chart abstraction validation report MacIntyre, Elaina 2008

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PERINATAL DATABASE REGISTRY CHART ABSTRACTION VALIDATION REPORT Elaina MacIntyre Michelle Linnegar Cornel Lencar Michael Brauer Paul Demers Aleck Ostry University of British Columbia June 15, 2006 Introduction As part of the Border Air Quality Study1 we have developed a birth cohort consisting of all children born in the Georgia Air Basin2 of British Columbia during 1999-2002. The goal of this study is to determine the impact of air pollution on various health outcomes (adverse birth outcomes, bronchiolitis, otitis media, bronchitis and asthma) during prenatal and early childhood development.  We have successfully linked children of this cohort to residential air pollution exposure histories beginning at conception. Our birth cohort has been linked to the BC Perinatal Database Registry to provide information about birth outcomes, medical conditions during pregnancy and socio- economic indicators. We are particularly interested in obtaining information on early exposure to tobacco smoke, directly through maternal smoking or less directly as “second-hand” smoke. This is important in order to properly control for confounding in our analyses of air pollution and respiratory health outcomes (such as asthma, bronchiolitis, otitis media).  The BC Reproductive Care Program was initiated in June 1988 with the objective of collecting and evaluating perinatal outcomes, care processes and resources via a province-wide computerized database, which led to the development of the BC Perinatal Database Registry (PDR)3. The mission of the PDR is to collect, maintain analyze and disseminate comprehensive, province-wide perinatal data for the purpose of monitoring and improving perinatal care. While participation is voluntary, the registry currently captures 99% of all births in the province. The database undergoes regular validation edits and quality checks.  Here we describe a chart abstraction study at BC Women and Children’s Hospital conducted to 1) determine the consistency with which key information on maternal risk factor data (parental occupation, ethnicity and education: environmental tobacco smoke exposure) is available from patient hospital charts and prenatal care records and recorded on the PDR ‘antenatal record’ data forms (but not coded and entered into the perinatal database itself) and 2) to assess the reliability of data coding from patient hospital charts and prenatal care into the perinatal database. Using our birth cohort, we have randomly select one percent of the files of women birthing at Women and Children’s hospital during each of our study years.  100 charts were been randomly sampled from each study year: 1999, 2000, 2001 and 2002. Maternal risk factor information of interest includes; maternal smoking and second hand smoking, breastfeeding, ethnicity, education and occupation.  BC Women and Children’s hospital was selected for the chart review because it has the largest number of births in the province (approximately 7,000/year). Additionally, this hospital receives referrals from all over the province, and because the antenatal form is completed by the primary care provider, this should allow for a reasonable snapshot of antenatal form data from the entire province.  1 See http://www.cher.ubc.ca/UBCBAQS/aboutthestudy.htm for more information. 2 Including the Lower Mainland, Eastern Vancouver Island, Sunshine Coast, and Fraser Valley. 3 See http://www.rcp.gov.bc.ca/ for more information.  1 Methodology Perinatal Database Registry staff provided the Hospital’s records department with identifying information for the patient files. These charts were retrieved and photocopied by a registered technician employed by the hospital with all personal identifying information removed. Specific data was then abstracted from the anonymized charts before comparison with the electronic file obtained from the PDR.  While there are many types of information collected on the PDR antenatal record form, we have considered a relatively small number of variables for this study. These specific variables were chosen based on information of importance for risk factors for childhood respiratory diseases and birth outcomes and based on results from a pilot study (Appendix 1). The following relevant data fields are presently included on the PDR antenatal record form and used in our analysis:  Ethnic origin of mother Ethnic origin of father Alcohol consumption during pregnancy T-ACE score Smoking before pregnancy Cigarettes per day Smoking during pregnancy Cigarettes per day Second hand smoke Number of school years completed by mother Mother’s work Hours worked per day and expected leave date Partner’s work Breastfeeding planned antenatally Table 1. Variables of interest on Antenatal Record Forms  However, only a subset of these fields are recorded into the PDR electronic database:  Alcohol consumption during pregnancy T-ACE score Smoking during pregnancy Cigarettes per day Breastfeeding planned antenatally Table 2. Variables of interest coded for Perinatal Database Registry  An additional data field, although not recorded on the antenatal record form, but available from hospital charts was also evaluated to generate summary information for this subset of subjects: ! Breastfeeding initiated prior to discharge   2 Validation was conducted to determine the consistency with which the variables listed in Table 1 were recorded in patient records. We also compared information from the chart review with the perinatal database to examine the accuracy of coding for the subset of variables (Table 2) included in the database.   In total, 401 records, 100 randomly selected from each year (one additional chart was reviewed for 1999), were reviewed. Relevant data from the patients chart were abstracted and entered into an Excel file.  Patient records that were analyzed (not all were completed for all patients) included: ! PDR Antenatal Record Form part 1 (Appendix 2) – completed by physician ! Pre-1999 Prenatal form used by  the PDR (pre-1999) ! Hospital discharge summary – completed by nurse ! Dictated discharge summary – completed by physician ! Physician progress notes ! Inter-professional progress notes ! Operative reports ! Outside letters and triage admission forms.  To assess breastfeeding initiation, the data sources most often used were discharge summary and inter-professional progress notes. For all other variables of interest, the data source most commonly used was the PDR antenatal record form.  On the PDR antenatal record form (Appendix 2), a checkmark indicates only that the subject has been discussed with the patient. Where there are concerns (as assessed by health care provider or patient) there is room for specific comments to be recorded.  Ethical approval for the study methodology was obtained from the University of British Columbia Behavioral Research Ethics Board. Results & Discussion Chart Review Of the 401 charts that were reviewed, seven did not include a PDR antenatal record form but had been entered into the Perinatal Database Registry4. In the subsequent tables we present summaries of data recorded on the PDR antenatal record form for each of the 394 charts.  Ethnicity On the PDR Antenatal form, demographic information is to be filled in at the primary care giver’s office. According to the perinatal forms guidelines (Appendix 3), the purpose of asking for both parents ethnicity is to appropriately screen for genetic diseases. Our  4 Other data sources were obtained from these charts such as physician progress notes, discharge summaries, social work reports, etc.  3 review found that maternal ethnicity status was recorded in 310 (79%) charts while paternal ethnicity status was recorded in only 262 (66%) charts (Table 3).  Maternal Paternal Number Percent Number Percent Aboriginal 6 2% 6 2% Asian 125 32% 104 26% Black 7 2% 6 2% Caucasian 119 30% 106 27% East-Indian 34 9% 32 8% Latino 19 5% 8 2% Not recorded 84 21% 132 34%    Table 3. Ethnic origin of parents   Alcohol consumption Alcohol consumption during pregnancy was recorded in 362 (92%) charts (Table 4). While 9 mothers reported occasional drinking, only one antenatal record form included a T-ACE score. The majority of mothers reported no alcohol use during pregnancy.    Number Percent Yes 9 2% No 353 90% Not recorded 32 8%        Table 4. Alcohol Consumption  Smoking Smoking status before pregnancy (either yes or no) was ascertained in 289 (74%) of the 394 charts and smoking status during pregnancy was ascertained in 353 (90%) of the 394 charts (Table 5). These results show that physicians more consistently record information on smoking during pregnancy versus prior to pregnancy. This may be partly due to the PDR including data on smoking during, but not prior to, pregnancy.   Before Pregnancy During Pregnancy Number Percent Number Percent Yes 26 7% 20 5% No 263 67% 333 85% Not recorded 105 26% 40 10% Can not determine5 - - 1 <1%          Table 5. Self-reported smoking status   5 PDR Antenatal Record Form was illegible.  4 Table 6 includes information on the level of smoking prior to and during pregnancy. Again, there were 67% and 85% that reported no smoking (“none”) prior to and during pregnancy, respectively. For those who reported smoking before pregnancy (n=26) amounts were missing in 7 charts and for those who reported smoking during pregnancy (n=20) amounts were missing in 3 charts. These numbers are reflected by slight increases in the “not recorded” section in Tables 5 and 6. Most mothers who reported smoking prior to and during pregnancy also reported a decrease in quantity smoked per day.   Before Pregnancy During Pregnancy Number Percent Number Percent >19 /day 3 <1% 1 <1% 10 – 19 /day 5 1% 3 1% 5 – 9 /day 3 <1% 6 2% < 5 /day 8 2% 7 2% None 263 67% 334 85% Not recorded 112 28% 43 10%   Table 6. Self-reported number of cigarettes per day smoked  Exposure to second hand smoke was recorded in 146 (37%) of the 394 charts that were reviewed (Table 7).  Of the 15 charts which reported exposure to second hand smoke; 2 were current smokers, 3 attributed exposure to workplace environments, 7 lived with current smokers, and 3 had no information about the source of exposure. In 248 (63%) of the charts there was no information about second hand smoke.   Number Percent Yes 15 4% No 131 33% Not recorded 248 63%        Table 7. Second hand smoke  Parental education In our chart review we found “number of school years completed” by mother to be the least consistently recorded field of all those examined (Table 8). There were 357 (91%) charts missing this information despite the fact that the guidelines for form completion highlight the importance of this information as an indicator of socioeconomic status. Of the 37 charts which included information on school years, only half reported the actual number of school years completed while the remainder reported the highest degree/diploma obtained. Of the 357 charts that left this section blank, it may be possible to sometimes use type of work (when completed) as a surrogate.    Number Percent Recorded 37 9% Not recorded 357 91%        Table 8. Educational status of mother  5 Parental Employment Information on mother’s employment status was recorded in 292 (74%) charts while information on partner’s employment status was recorded in only 223 (57%) charts (Table 9). Unlike ethnicity, some of the discrepancy for employment, between mother and partner, may be attributed to single parent families. There is no option on the present PDR antenatal record form to indicate the absence of a partner, thus where the field was empty and considered here as “not recorded” it may actually have been non-applicable. Where the data was obtained, most of the mothers were presently working (260 out of 292) and most partners were working (215 out of 223).   Mother Partner Number Percent Number Percent Yes 260 66% 215 55% No 32 8% 8 2% Not recorded 102 26% 168 43% Can not determine - - 3 1% Table 9. Employment status6 of parents  Breastfeeding In the section ‘topics for discussion’ of the PDR Antenatal Record Form women are asked their plans for breastfeeding (Appendix 2). The form is laid out so that a checkmark beside ‘breastfeeding’ indicates that the topic has been discussed with the patient and a second checkmark beside ‘yes’ or beside ‘no’ indicates that they have decided (or not) to breastfeed. As can be seen in Table 10, this field was rarely completed. Breastfeeding was only discussed in 42 (11%) charts. Also, of the women who discussed breastfeeding with their doctor, approximately one-third had made a decision.   Number Percent Yes 10 3% No 3 1% Discussed but undecided 29 7% Not recorded/discussed 352 89%           Table 10. Breastfeeding planned during pregnancy  Feeding patterns were assessed for each newborn prior to being discharged from the hospital. While this information is not recorded in the PDR antenatal record form, it is obtained from other data sources within the patients chart and entered into the PDR. Table 11 shows the type of feeding initiated for the 392 newborns (394 minus 2 stillbirths). In 344 (88%) of the charts the mother was able to initiate breastfeeding (either exclusively or in combination with bottle feeding).   6 “yes” for employment status included those who reported as homemakers, “no” included those who reported as unemployed.  6 Of the 48 (12%) children who were recorded as being bottle fed, 13 were fed with expressed breast milk.  Expressed breast milk (EBM) is pumped breast milk, and was most commonly used because the mother had difficulty directly breastfeeding or was unable to breastfeed because the newborn had been placed in the intensive care unit. In examining breastfeeding as a protective risk factor for childhood respiratory disease there is potential for misclassification due to the strict usage of the terms in Table 10. When newborns fed with EBM are included in the overall breastfeeding group the actual proportion who received breast milk becomes slightly higher at 91%.   Number Percent Breastfed exclusively 147 38% Mixed bottle and breastfeeding 197 50% Bottle/Other 48 12%  Table 11. Type of feeding initiated prior to discharge  Summary of chart review and recording of information. Table 12 provides a breakdown by year of the incomplete charts (referred to as ‘not recorded’) for each of the data fields reported thus far.  For most variables there is little difference from year to year. In general, only smoking and alcohol consumption were recorded in sufficiently high percentages to warrant use in epidemiological analyses.     Birth Year   1999 2000 2001 2002 Total Ethnicity maternal  22 17 21 24 84 paternal 34 29 29 40 132  Alcohol consumption 6 10 4 12 32  Smoking before pregnancy 9 26 35 35 105 during pregnancy 3 12 11 14 40 Second hand smoke 89 64 49 46 248  Education  mother 97 86 86 88 357  Employment mother  25 22 32 23 102 partner 37 32 52 47 168  Plan to breastfeed 89 87 87 89 352 Total Charts Reviewed 99 99 98 98 394          Table 12. Incomplete charts by data field and year   7 Comparison with the Perinatal Database Registry Comparison was made between the PDR antenatal record form and the perinatal database for the following fields: ! alcohol consumption during pregnancy ! T-ACE score ! smoking during pregnancy ! number of cigarettes per day ! breastfeeding planned antenatally. The perinatal database considers only information from the “social history” section of the PDR antenatal record form for these variables (Appendix 2) and no other sources of data within the patients chart are used. Tables 13-17 show the distribution of responses in each category for the chart review and as recorded in the database.  Smoking For smoking during pregnancy (Table 13), we identified 262 charts that were recorded into the database as unknowns (left blank) but for which the chart review classified the subjects as nonsmokers. Of the 15 current smokers who were correctly recorded as such in the PDR, 13 included information on amount smoked in both their chart and database entry. The PDR identified 6 current smokers who, according to their chart reviews, did not smoke during pregnancy. Smoking status prior to pregnancy for these 6 charts identified three former smokers and two never smokers (one not recorded). For the chart review, the Antenatal Record form was used to assess smoking status for 5 of these charts (in one chart smoking status was determined from the triage form). The perinatal database recorded 3 current nonsmokers who, according to their chart reviews, were actually smokers during pregnancy. Of these three, all were smokers prior to becoming pregnant and all reported the quantity smoked during pregnancy. The perinatal database also recorded blanks for two subjects identified as smokers during pregnancy from the chart review. Of these two, both were smokers prior to pregnancy and one listed the amount smoked. Finally, there were 6 charts for which we were unable to ascertain smoking status during the chart review but were recorded in the perinatal database as nonsmokers.                 Chart Review Database Yes No Not Recorded Total Yes 15 6 - 21 No 3 65 6 74 Blank 2 262 35 299   Table 13. Comparison for smoking during pregnancy  If there was perfect agreement between the chart review and the perinatal database we would see 100% sensitivity and 100% specificity, instead we calculated a sensitivity of  8 75% and a specificity of 20%7. This means that a true smoker is accurately identified 75% of the time and a true nonsmoker is accurately identified only 20% of the time.  Because such a large number of nonsmokers (262) were entered into the database as blanks, we decided to combine the ‘no’ and ‘blank’ rows. From Table 14 the sensitivity is 75% and the specificity is 98%. The specificity increased almost five-fold, indicating that nonsmokers are likely to be entered into the perinatal database as blanks for this variable.  .                Chart Review Database Yes No Not Recorded Total Yes 15 6 - 21 No/Blank 5 327 41 373   Table 14. Comparison for smoking during pregnancy  Alcohol The sensitivity (100%) and specificity (99%) for alcohol consumption during pregnancy was excellent (Table 15). As in Table 14, patients with no data entered into the database (‘blank’) were collapsed with ‘no’. Of the two charts recorded into the perinatal database as ‘yes’ for alcohol consumption but in the chart review as ‘no’, one did have a Ministry alert for drug and alcohol use. For the 394 charts reviewed, only one chart contained a T- ACE score on the antenatal record form. The database comparison did not identify any T- ACE scores. It is not known why the one T-ACE score identified through our chart review was not recorded into the perinatal database.                  Chart Review Database Yes No Not Recorded Total Yes 9 2 1 12 No/Blank - 351 1 352 Unknown - - 30 30   Table 15. Comparison for alcohol consumption during pregnancy  Breastfeeding Technically, breastfeeding planned antenatally is collected from two PDR forms: the “Antenatal Record Part 1” and the “Newborn Record Part 1”. However, the breastfeeding section on the newborn record form is rarely completed8. Thus, the Antenatal Record form is the best source for this data, but as we presented in Table 10, this field is rarely completed. Table 16 highlights the problems with this data field; sensitivity and specificity are both zero.   7 Sensitivity is calculated as the proportion of true positives (chart review – yes) correctly identified as positive (yes) in the database. Specificity is calculated as the proportion of true negatives (chart review – no) correctly identified as negative (no) in the database. 8 Personal communication with Wendy Kearns, Data Quality Analyst.  9                 Chart Review Database Yes No Discussed/ Undecided Not Recorded Total Yes - - 1 - 1 No - - - 5 5 Unknown/Blank 10 3 28 347 388     Table 16. Comparison for breastfeeding planned antenatally  As discussed for Table 11, there were some discrepancies in the recording of the ‘breastfeeding initiated at time of discharge’ variable. For the PDR, feeding of expressed breast milk (alone or in combination with formula) is abstracted as breastfeeding. Similarly to Table 14, we collapsed ‘blank’ charts with ‘yes’ for breastfeeding status from the perinatal database (Table 17).  The sensitivity is 95% and specificity is 73%.                  Chart Review Database Yes (breastfeeding & mixed) No (bottle/other) Not Recorded Total Yes/Blank 328 13 - 341 No 16 35 2(stillborn) 53      Table 17. Comparison for breastfeeding initiated at time of discharge  Conclusion Overall, we found that maternal and paternal ethnicity is recorded in approximately 79 and 66 percent of PDR Antenatal Record forms, respectively and thus would be a variable that would offer reasonably useful data if coded and entered into the PDR. Only 10% of our chart abstractions contained information on maternal educational status while maternal employment status was recorded in 74% of our charts and was specified in all instances. It may sometimes be possible to infer educational status from job specifics (ex. sales manager, lawyer, pharmacist), but certainly not in all cases (ex. housewife, student). Therefore, there appears to be little opportunity to enter reliable information regarding educational status, but strong possibilities for entry of occupational information in the PDR. Partner’s employment status was recorded in 57% of the charts we abstracted. These results were all similar to our original findings in the pilot study (Appendix 1).  Results for alcohol consumption and smoking status were slightly better than what was found during the pilot study and indicated that these variables are being reliably recorded in the PDR. Of the charts reviewed, 92% included alcohol consumption during pregnancy. Smoking status during pregnancy was ascertained in 90% of the charts reviewed while smoking status prior to pregnancy was ascertained in only 74%. Similarly, the quantity smoked per day was recorded for 85% of current smokers and 73% of former smokers. Second hand smoke exposure was recorded in only 37% of the charts and therefore does not appear to be ascertained adequately for incorporation in epidemiological analyses.  10  Breastfeeding planned antenatally was poorly recorded (11%), but type of feeding initiated at time of discharge from hospital was ascertained for every chart abstracted9 and therefore would appear to provide reliable information about breastfeeding initiation.  In examining the accuracy with which data is entered into the PDR, there was some misclassification with respect to blank entries. For smoking status and alcohol consumption, a large proportion of ‘no’ charts were entered into the PDR as blank fields (n=262 and 351, respectively). For breastfeeding the opposite was found, a large proportion of ‘yes’ charts were entered as blank fields (n=326). There was no trend in this finding across the four years studied.  Additionally, while the sensitivities and specificities for smoking status and alcohol consumption were quite high (after collapsing blank entries), this reflected only charts where these variables were recorded. There were 41 and 32 charts missing data for smoking during pregnancy and alcohol consumption, respectively. There is no such limitation with the sensitivity and specificity calculated for breastfeeding initiation because this variable was recorded for every live birth.  The results from this sub-study indicate that, during the period of interest, breastfeeding initiation and smoking status during pregnancy were routinely recorded on the PDR antenatal record form. Further, after collapsing blank entries in the perinatal database, the coding of these variables had high sensitivity and specificity. Both of these variables are of interest to the Border Air Quality Study. Breastfeeding tends to protect infants and children from respiratory infections through passive immunity while secondhand smoke exposure is a known risk factor for many of the health outcomes being considered in the study. These variables also tend to be correlated with socioeconomic status.   9 Excluding stillbirths.  11 Appendix 1 – Pilot Study A pilot sample of 48 hospital charts from BC Children and Women’s Hospital were randomly selected. This sample consisted of 12 charts from each of the years 1999, 2000, 2001 and 2002. To ensure that smoking history could be evaluated we obtained an additional 12 hospital charts (3 randomly selected from each year) of known smokers.  These charts were reviewed in detail to evaluate the availability of any exposure and social determinants risk factor information. Following this evaluation we determined that at least partial information was available for the following variables to be evaluated in more detail: smoking before pregnancy, number of cigarettes per day, smoking during pregnancy*, number of cigarettes per day*, second hand smoke, alcohol consumption during pregnancy*, ethnic origin of mother, ethnic origin of father, employment status of mother, employment status of partner, mother’s occupation, partner’s occupation, educational attainment for mother, initiation of breastfeeding* (*coded for by the perinatal database).  Random Chart Review (n=48) For the alcohol consumption variable: 40 women had no concerns and 8 had no information recorded (not discussed). No T-ACE scores were reported. For the drug use variable: 6 women had no concerns, 11 had no history, 23 reported no drug use and 8 had no information recorded (not discussed). For the smoking before pregnancy variable: 17 women had no concerns about smoking before pregnancy, 12 had no history of smoking, 9 were not presently smokers and 10 had nothing recorded (not discussed). Of these, two women reported smoking in the past but no information was recorded regarding the quantity. For the smoking during pregnancy variable: 13 women had no concerns, 11 had no history of smoking, 17 were not presently smokers and 7 had no information recorded (not discussed). There was no information on quantity recorded. Mother’s ethnic status was properly recorded in 40 charts (2 charts were not usable and 6 charts had no information). Father’s ethnic status was properly recorded in 30 charts (3 unusable and 15 had no information). Mother’s education was properly recorded in 5 charts, 43 had no information. Mother’s occupation was recorded in 32 charts (29 recorded specifics of mothers work and 3 did not work). Father’s occupation was recorded in 25 of the 48 charts reviewed.  12   Discussed risk factor with patienta Patient concerned about risk factorb Alcohol  40/48 = 83% none Drug use 40/48 = 83% none Smoking - before pregnancy  38/48 = 80% 21 (out of 38)             - during pregnancy 31/48 = 65% 18 (out of 31) a indicated by a check mark. b indicated by additional comments.   Recorded Ethnic status - mother 40/48 = 83%                      - father 30/48 = 63% Education     - mother 5/48 = 10% Occupation   - mother 32/48 = 67%                - partner 25/48 = 52%  We would expect that a random sample would identify several smokers but according to the chart review only 2 prior smokers were identified. This is quite low and indicates that smoking before pregnancy and during pregnancy might be under-recorded. The main form used to record smoking information has a vague way of recording this information. The PDR antenatal record form has a box labeled “discussed” which the recorder can check. If checked, and there is no amount listed in the ‘number of cigarettes per day’ line this presumably means that the woman is not a smoker. Additionally, 10 of 48 forms were not filled in for smoking prior to pregnancy which may also explain the under- ascertainment of smoking. Ideally, we would like to compare the recorded prevalence of smoking to some gold standard (probably the expected smoking prevalence for pregnant women in Vancouver). The related issue of course is whether this information gets translated onto the perinatal electronic database registry. It is not possible to interpret chart fields where no data has been recorded. This missing information could indicate that the issue was not discussed or that it was not felt to be important or, in the case of yes/no answers, that the mother responded “no”. Mother’s ethnic status seems to be obtainable from these charts, father’s ethnic status is less consistently recorded but may also be obtainable. Of the 29 mothers who reported that they were presently working, all charts included specifics. 23 charts were missing any information on father’s occupation, once again this could be interpreted in numerous ways: not discussed at visit, father not currently working or father not involved with pregnancy. Data on alcohol and drug use were consistently recorded. Educational status is the most poorly recorded data of those considered.  Known Smoker Chart Review (n=12) For the smoking before pregnancy variable: 9 reported smoking and 3 reported no smoking. Of these, 5 women reported the quantity of cigarettes smoked on a daily basis. For the smoking during pregnancy variable: 10 were presently smokers and 2 reported no smoking. Of these, 9 reported the quantity of cigarettes smoked per day. Of these 12 known smokers, 1 reported exposure to passive tobacco smoke, 2 reported that they were not concerned about passive smoke exposure and 9 had nothing recorded.  13   Smoking Recorded as smokers Information on quantity before pregnancy   9/12 = 75% 5 (out of 9) during pregnancy 10/12 = 83% 9 (out of 10)   Discussed risk factor with patienta Patient concerned about risk factorb Second hand smoke 3/12 = 25% 1 (out of 3) a indicated by a check mark. b indicated by additional comments.  We know that these 12 people smoked either before and/or during pregnancy but there is virtually no information on passive smoking. Of those who reported smoking before pregnancy, the quantity was only listed for about half (5/9) but for those who reported smoking during pregnancy the quantity was listed for almost all (9/10).   14 Appendix 2 – PDR Antenatal Record Form  15 1. British Columbia Antenatal Record Part  1 HOSPITAL PRIMARY CARE GIVER FAMILY PHYSICIAN AGE ETHNIC ORIGIN OF NEWBORN’S FATHER LANGUAGE PREFERRED AGE AT EDD  MOTHER'S NAME MOTHER'S MAIDEN NAME ETHNIC ORIGIN PARTNER'S  NAME DATE OF BIRTH D         M          Y SIGNATURE: MD/RM  HLTH 1582-1 Rev. Rev. 02/03  Prepared by: The British Columbia Reproductive Care Program  WHITE- MOTHER'S CHART YELLOW - INFANT’S CHART PINK - PHYSICIAN/ MIDWIFE DATE SURNAME GIVEN NAME ADDRESS PHONE NUMBER PERSONAL HEALTH NUMBER PHYSICIAN / MIDWIFE NAME INFORMED CONSENT (in compliance with the Freedom of Information and Protection of Privacy Act, Oct. 1993) .  I understand that providing this information is necessary to assist the physician/midwife in planning my care throughout pregnancy, childbirth and postpartum; my personal information will be kept private. I also understand this information may be reviewed when necessary by other health professionals directly involved in my care.  This information is collected in accordance with the provisions of the Freedom of Information and the Protection of Privacy Act by the Perinatal Database Registry, an integral part of the Ministry of Health supported and funded British Columbia Reproductive Care Program.  I understand that I can ask my care provider if I have any questions regarding the collection and use of this information. Mother's Signature: Witness: Date: 2. no yes (specify) OPERATIONS CV OR RESPIRATORY ANESTHETIC PROBLEMS Rx BLOOD PRODUCTS INFECTIONS, STDS etc. SUSCEPTIBLE TO CHICKEN POX THROMBOEMBOLIC / COAG. HYPERTENSION GI URINARY DIABETES OR ENDOCRINE SEIZURE OR NEUROLOGIC DEPRESSION OR PSYCHIATRIC OTHER BIRTH WEIGHTPERINATAL COMPLICATIONS CHILDREN WEEKS AT DELIVERY HOSPITAL OF BIRTH  OR ABORTION DELIVERY TYPE 3.  OBSTETRICAL HISTORY INCLUDING ABORTIONS DATE SEX PRESENTHEALTH Gravida Term Preterm Abortion Living HRS.IN ACTIVE LABOUR D M Y 4. 7.   PRESENT PREGNANCY CONTRACEPTION METHOD: 6. BELIEFS & PRACTICES COMPLEMENTARY Rx's EDD BY DATESLMP CURRENT MEDICATIONS discussed concerns (specify) NUTRITION SPECIAL DIET FOLIC ACID start date: ALCOHOL T-ACE SCORE (see reverse): DRUGS (OTC's, vitamins) SUBSTANCE USE IPV SMOKING (before pregnancy) Cigs./day SMOKING (currently) Cigs./day SECOND HAND SMOKE FINANCIAL/HOUSING SUPPORT SYSTEMS NUMBER OF SCHOOL YEARS COMPLETED: WORK (specify type): hours worked per day: quitting date: partner's work: EARLY COMMUNITY SERVICES REFERRAL OTHER  REFERRAL MUSCULOSKELETAL &SPINE VARICES & SKIN PELVIC EXAM SWABS / CERVIX CYTOLOGY 13. BP 10.  FAMILY HISTORY 11.  EXAMINATION D M Y D M Y MENSES CYCLE WHEN STOPPED: D M Y EDD BY US 8. PAST ILLNESS no HEART DISEASE HYPERTENSION DIABETES DEPRESSION OR PSYCHIATRIC ALCOHOL/ DRUG USE THROMBOEMBOLIC / COAG. INHERITED DISEASE/DEFECT ETHNIC ( e.g. Taysachs, Sickle) OTHER SUMMARY 9. SOCIAL HISTORY D     M       Y 12. TOPICS FOR DISCUSSION Rest / Preterm Labour Sexual Relations GBS Management VBAC Hospital Admission/ Procedures Birth Plan Pain Management Baby's Best Chance Prenatal Education Breastfeeding plans to BF   yes   no Breast / Nipple Care Exercises Genetic Counselling HIV Testing Call Schedule Labour Stages C-Section Baby Care SIDS Prevention Circumcision HEAD & NECK BREAST / NIPPLES HEART & LUNGS ABDOMEN no yes (specify) BLEEDING NAUSEA INFECTIONS OR FEVER DEPRESSION OTHER MATERNAL PATERNAL yes (specify) 5. ALLERGIES      NONE KNOWN  YES (specify): I have discussed the benefits and risks of planned or potential transfusion therapy    Maternal serum screening offered of blood and/or blood products with the patient Appendix 3 – Perinatal Forms Guideline   16 RISK IDENTIFICATION PAST OBSTETRICAL HISTORY RISK FACTORS Neonatal death Stillbirth Abortion ( 12 - 20 weeks ) Habitual abortion ( 3+ ) Prior preterm birth ( 33 - 36 wks. ) Prior preterm birth ( 20 - 33 wks. ) Prior Cesarean birth ( uterine surgery ) Prior IUGR baby Prior macrosomic baby Rh Immunized ( antibodies present ) Prior Rh affected preg. with NB exchange or prem. Major congenital anomalies (eg. Cardiac, CNS, Down's Syndrome.) P.P. Hemorrhage PROBLEMS IN CURRENT PREGNANCY RISK FACTOR Diagnosis of large for dates Diagnosis of small for dates (IUGR) Polyhydramnios or oligohydramnios Multiple pregnancy Malpresentations Membrane rupture before 37 weeks Bleeding Pregnancy induced hypertension Proteinuria > 1+ Gestational diabetes documented Blood antibodies (Rh, Anti C, Anti K, etc.) Anemia  ( < 100g per L ) Admission in preterm labour Pregnancy ≥ 42 weeks Poor weight gain 26 - 36 weeks ( <.5 kg / wk ) or weight loss MEDICAL HISTORY RISK FACTORS DIABETES Controlled by diet only Diet only macrosomic fetus Insulin dependent Retinopathy documented HEART DISEASE Asymptomatic (no effect on daily living) Symptomatic ( affects daily living) HYPERTENSION 140 / 90 Hypertensive drugs Chronic renal disease documented OTHER Age under 18 at delivery Age 35 or over at delivery Obesity (equal or more than 90kg. or 200 lbs.) Height (under 1.57 m  5 ft.  2 in.) Height (under 1.52 m  5 ft.  0 in.) Depression Alcohol and Drugs Smoking any time during pregnancy Other medical / surgical disorders e.g. epilepsy, severe asthma, Lupus etc. Reference: Sokol, R et al. The T-ACE Questions, Pratical Prenatal Detection of Risk Drinking, American Journal of Obstetrics and Gynaecology, Vol. 160, No. 4 April 1989. T olerance How many drinks does it take to make you feel high? Score 2 for more than 2 drinks Score 0 for 2 drinks or less Score 1 point for each Yes answer to the following : A nnoyance Have people annoyed you by criticizing your drinking? C ut down Have you felt that you ought to cut down on your drinking? E  ye opener Have you ever had a drink first thing in the morning to steady your nerves or get rid of a hangover? High Risk Score = 2 or more points CARDIAC CLASSIFICATION (New York Heart Association) CLASS I No limitation of physical activity. CLASS II Slight limitation of physical activity. CLASS III Marked limitation of physical activity. CLASS IV Inability to perform any physical activity without discomfort. Reference:Williams Obstetrics. (20 th Ed.) 1997, Appleton and Lange T-ACE  QUESTIONNAIRE


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