Ill. Admin. Code tit. 77, § 640.APPENDIX I – Perinatal Reporting System Data Elements

1. Child's First Name
2. Child's Middle Name
3. Child's Last Name
4. Child's Suffix
5. AKA
6. Child's Date of Birth
7. Child's Time of Birth
8. Sex
1. A. Male
2. B. Female
3. C. Ambiguous
9. Child of Hispanic Origin
A. Yes
Cuban
Mexican
Puerto Rican
B. No
1. 10. Race
  1. A. Asian
  2. B. Black
  3. C. Caucasian
  4. D. Native American
  5. E. Other
2. 11. Place of Birth
3. 12. City of Birth
4. 13. County of Birth
5. 14. Mother's First Name
6. 15. Mother's Middle Name
7. 16. Mother's Last Name
8. 17. Mother's Maiden Name
9. 18. Mother's Social Security Number
10. 19. Mother's Date of Birth
11. 20. Mother's Street Number
12. 21. Mother's Street Name
13. 22. Mother's Street Direction
14. 23. Mother's Street Type
15. 24. Mother's Street Location
16. 25. Mother's City
17. 26. Mother's County
18. 27. Mother's Zip Code
19. 28. Mother's State
20. 29. Mother's Telephone
21. 30. Mother's Age
22. 31. Mother's Birthplace
  1. A. ________State
  2. B. ________County
23. 32. Mother of Hispanic Origin
  1. A. Yes
    Cuban
    Mexican
    Puerto Rican
  2. B. No
24. 33. Mother's Race
  1. A. Asian
  2. B. Black
  3. C. Caucasian
  4. D. Native American
  5. E. Other
25. 34. Mother's Education (specify highest grade completed)
35. Mother's Occupation
1. 36. Mother's Business/Industry
2. 37. Mother Employed During Pregnancy
  1. A. Yes
  2. B. No
  3. C. Record Not Available (N/A)
  4. D. Not Stated
3. 38. Marital Status
  1. A. Married
  2. B. Not Married
4. 39. Father's Last Name
5. 40. Father's Middle Name
6. 41. Father's First Name
7. 42. Father of Hispanic Origin
  1. A. Yes
    Cuban
    Mexican
    Puerto Rican
  2. B. No
8. 43. Father's Race
  1. A. Asian
  2. B. Black
  3. C. Caucasian
  4. D. Native American
  5. E. Other
9. 44. Father's Education (specify highest grade completed)
10. 45. Father's Age
11. 46. Father's Occupation
  ________________
_________________
47. Father's Business/Industry
1. 48. Father Employed
  1. A. Yes
  2. B. No
  3. C. Record N/A
  4. D. Not Stated
2. 49. Pregnancy History
3. 50. Plurality (# this Birth)
  If greater than 1, Birth Order of this Birth
4. 51. Previous Live Births
5. 52. Number Live Births Now Living
6. 53. Number Live Births Now Dead
7. 54. Date of Last Live Birth
8. 55. Previous Terminations
9. 56. Number of Other Terminations
10. 57. Date of Last Other Termination
11. 58. Date of Last Normal Menses
12. 59. Month Prenatal Care Began
13. 60. Number of Prenatal Care Visits
14. 61. 1 Minute Apgar Score
15. 62. 5 Minute Apgar Score
16. 63. Estimate of Number of Gestation Weeks
17. 64. Mother Transferred In Prior to Delivery
  1. A. Yes
  2. B. Name of Hospital ________________
    Location of Hospital ________________
  3. C. No
18. 65. Infant Transferred (Out)
  1. A. Yes
  2. B. Name of Hospital ____________
    Location of Hospital ____________
  3. C. Transfer Code
  4. D. No
19. 66. Reporting Hospital
20. 67. Reporting Hospital City
21. 68. Tobacco Use During Pregnancy
22. A. Smoked during pregnancy
  1. B. Stopped smoking during pregnancy
  2. C. Does not smoke
  3. D. Record N/A
  4. E. Not Stated
  Average cigarettes per day _____________
23. 69. Alcohol Use During Pregnancy
  1. A. Yes
    Average number drinks per day ______
  2. B. No
  3. C. Record N/A
  4. D. Not Stated
24. 70. Mother's Weight Gain
  1. A. Yes
    Pounds ______
  2. B. No
  3. C. Record N/A
  4. D. Not Stated
25. 71. Mother's Weight Loss
  1. A. Yes
    Pounds ______
  2. B. No
  3. C. Record N/A
  4. D. Not Stated
26. 72. Medical Risk Factors for this Pregnancy
  1. A. Anemia
  2. B. Cardiac Disease
  3. C. Acute or Chronic Lung Disease
  4. D. Diabetes
  5. E. Genital Herpes
  6. F. Hydramnios/Oligohydramnios
  7. G. Hemoglobinopathy
  8. H. Hypertension, Chronic
  9. I. Hypertension, Pregnancy-related
  10. J. Eclampsia
  11. K. Incompetent Cervix
  12. L. Previous Infant 4000 + Grams
  13. M. Previous Preterm or Small-for-Gestational-Age (SGA) Infant
  14. N. Renal Disease
  15. O. Rh Sensitization
  16. P. Uterine Bleeding
  17. Q. None
  18. R. Other, Specify
27. 73. Obstetric Procedures
  1. A. Amniocentesis
  2. B. Electronic Fetal Monitoring
    Internal
    External
    Both
    Neither
    Record N/A
    Not Stated
  3. C. Induction of Labor
  4. D. Stimulation of Labor
    Yes
    Pitocin _____
    Oxytocin _____
    No
    Record N/A
    Not Stated
  5. E. Tocolysis
  6. F. Ultrasound
  7. G. None
  8. H. Other, Specify
28. 74. Complications of Labor and/or Delivery
  1. A. Febrile
  2. B. Meconium
  3. C. Premature Rupture
  4. D. Abruptio Placenta
  5. E. Placenta Previa
  6. F. Other Excessive Bleeding
  7. G. Seizures During Labor
  8. H. Precipitous Labor
  9. I. Prolonged Labor
  10. J. Dysfunctional Labor
  11. K. Breech/Malpresentation
  12. L. Cephalopelvic Disportion
  13. M. Cord Prolapse
  14. N. Anesthetic Complications
  15. O. Fetal Distress
  16. P. None
  17. Q. Other, Specify
29. 75. Method of Delivery
  1. A. Spontaneous Vaginal
  2. B. Mid – Low Forceps
  3. C. Vacuum Extraction
  4. D. Vaginal Breech
  5. E. Caesarean Section Primary
  6. F. Caesarean Section Repeat
  7. G. Other Type
  8. H. Record N/A
  9. I. Not Stated
  10. J. Vaginal Birth After Previous Caesarean Section (VBAC)
  11. K. Other Caesarean Section
30. 76. Abnormal Conditions of Newborn
31. 77. Anemia
32. 78. Birth Injury
33. 79. Fetal Alcohol Syndrome
34. 80. Hyaline Membrane Disease
35. 81. Meconium Aspiration Syndrome
36. 82. Assisted Ventilation > 30 min.
37. 83. Assisted Ventilation = 30 min.
38. 84. Seizures
39. 85. Human Immunodeficiency Virus (HIV)
40. 86. Other, Specify
41. 87. Congenital Anomalies of Newborn
42. 88. Anencephalous
43. 89. Congenital Syphilis
44. 90. Hypothyroidism
45. 91. Adrenogenital Syndrome
46. 92. Inborn Errors of Metabolism
47. 93. Cystic Fibrosis
48. 94. Immune Deficiency Disorder
49. 95. Retinopathy of Prematurity
50. 96. Chorioretinitis
51. 97. Strabismus
52. 98. Intrauterine Growth Restriction
53. 99. Cerebral Lipidoses
54. 100. Spina Bifida/Meningocele
55. 101. Hydrocephalus
56. 102. Microcephalus
57. 103. Other CNS Anomalies, Specify ____________
58. 104. Heart Malformations, Specify _____________
59. 105. Other Circulatory/Respiratory Anomalies, Specify ____________
60. 106. Rectal Atresia/Stenosis
61. 107. Tracheoesophageal Fistula/Esophageal Atresia
62. 108. Omphalocele/Gastroschisis
63. 109. Other Gastrointestinal Anomaly
64. 110. Malformed Genitalia
65. 111. Renal Agenesis
66. 112. Other Urogenital Anomaly, Specify ____________
67. 113. Cleft Lip/Palate, Specify ____________
68. 114. Polydactyly/Syndactyly/Adactyly
69. 115. Club Foot
70. 116. Diaphragmatic Hernia
71. 117. Other Musculoskeletal/Integumental Anomaly
72. 118. Down's Syndrome
73. 119. Other Chromosomal Anomaly, Specify ____________
74. 120. None
75. 121. Other, Specify ____________
76. 122. Transfusion
77. 123. Anesthesia
  1. A. Local/ Pudendal
  2. B. Regional
  3. C. General
78. 124. Umbilical Cord Blood Gases Tested
  1. A. Yes
  2. B. No
79. 125. Small-for-Gestational-Age (SGA)
80. 126. Infection of Newborn Acquired Before Birth
81. 127. Infection of Newborn Acquired During Birth
82. 128. Infection of Newborn Acquired After Birth
83. 129. Hereditary Hemolytic Anemias
84. 130. Hemolytic Diseases of the Newborn
85. 131. Due to Rh Incompatibility Only
86. 132. Due to ABO Incompatibility
87. 133. Due to Other Causes
88. 134. Drug Toxicity or Withdrawal
  1. A. Yes, Specify ____________
  2. B. No
89. 135. Highest Bilirubin, Total ________
90. 136. Admit to Designated Patient Unit
  1. A. Yes
  2. B. No
91. 137. Genetic Screenings Conducted
92. 138. Rh Determination
  1. A. Mother's Blood Type _______ Rh Factor _______
    Immune Globulin Given
  2. B. Yes
  3. C. No
93. 139. Hepatitis B – Surface Antigen
  1. A. Positive
  2. B. Negative
94. 140. Non-Obstetrical Infections
  1. A. Syphilis
  2. B. Gonorrhea
  3. C. Rubella
  4. D. Other
95. 141. Obstetrical Infections
  1. A. Antepartum
    Amnionitis/Chorioamnionitis
    Urinary Tract Infection
  2. B. Postpartum
    Endometritis
    Infection of Wound
    Urinary Tract Infection
96. 142. Mother admitted within 72 hours after delivery
  1. A. Precipitous Delivery
  2. B. Planned Home Birth
97. 143. Drug Use During Pregnancy
  1. A. Cocaine
  2. B. Heroin
  3. C. Marijuana
  4. D. Other Street Drugs
  5. E. None
  6. F. Record N/A
  7. G. Not Stated
98. 144. Transfusion
99. 145. Prenatal Screening Conducted for
  1. A. Gestational Diabetes
    (Blood Glucose Tolerance Test)
  2. B. Congenital/Birth Defects
    1. A. Maternal Alpha Feta Protein
    2. B. Chromosomal
    3. C. Other
  3. 146. Number of Days Maintained on Ventilation Before Transfer to Level III Center-Days
100. 147. Prenatal Ultrasound
  1. A. Yes
  2. B. No
  3. C. Record N/A
  4. D. Not Stated
101. 148. Chorionic Villus Sampling
102. 149. Were Newborn Screening Tests Conducted?
  1. A. Yes
  2. B. No
103. 150. Mother Transferred Out to Another Hospital After Delivery Destination Hospital Code
104. 151. Mother Transferred From Emergency Room
105. 152. Infant Transferred In Transfer Code
106. 153. Consult Administrative Perinatal Center or Another Level III
107. 154. Infant Maternal
  A. A. Yes, with Transfer
  B. B. Yes, No Transfer
  C. C. No Consultation
  D. D. Not Stated
108. 155. Mother Died In Hospital
109. 156. Fetal Death
110. 157. Infant Died in Hospital
111. 158. Extrauterine Pregnancy
112. 159. Ectopic Pregnancy
113. 160. Admission Date – Infant
114. 161. Admission Date – Maternal
115. 162. Discharge Date – Infant
116. 163. Discharge Date – Maternal
117. 164. Payment Method
  1. A. Yes
    Medicaid
    Medicaid HMO
    HMO
    Medicare
    CHAMPUS
    Title V
    Health Insurance
    Self Pay
    Not Stated
    Other, Specify __________
  2. B. No
118. 165. Were prenatal records available prior to delivery?
  1. A. Yes
  2. B. No
119. 166. Maternal Diagnosis (Specify up to 8 Diagnoses)
120. 167. Mother's Medical Record Number _________________
__________________
168. Infant Diagnoses (Including Congenital Anomalies); Specify up to 8 Diagnoses
1. 169. Infant Released to:
  A. Home
  B. Other Hospital Name and Location
  C. Long Term Care Name and Location
  D. Other Child Care Agency Name and Location
2. 170. Infant Patient ID
3. 171. Infant Medical Record Number __________________
4. 172. Referrals
  1. A. Community Social Services
  2. B. Division of Specialized Services for Children (DSCC)
  3. C. Department of Healthcare and Family Services (HFS)
  4. D. Department of Children and Family Services (DCFS)
  5. E. Other, Specify _________________
  6. F. None
  7. G. Early Intervention program
  8. H. Other _______________
5. 173. Feedings
6. 174. Breast Fed
7. 175. Bottle
8. 176. Tube
9. 177. Formula
10. 178. Frequency
11. 179. Amount
12. 180. Infant Medications
13. 181. Birth Weight
14. 182. Birth Head Circumference
15. 183. Birth Length
16. 184. Discharge Weight
17. 185. Discharge Head Circumference
18. 186. Discharge Length
19. 187. Infant Discharge Treatment
20. 188. Other Concerns
21. 189. RN Contact at Hospital – Phone Number
22. 190. Relative/Friend
23. 191. Relationship
24. 192. Address/Phone #
25. 193. Family Informed of Local Health Nurse Visit
  1. A. Yes
  2. B. No
26. 194. Primary Care Physician's Name –
27. 195. Mother Gravida Para F_ P_ A_ L_
28. 196. Signature
29. 197. Title
30. 198. Report Date

(Source: Amended at 35 Ill. Reg. 2583, effective January 31, 2011)

A.	A.	Yes, with Transfer

B.	B.	Yes, No Transfer

C.	C.	No Consultation

D.	D.	Not Stated

A. Home

B. Other Hospital	Name and Location

C. Long Term Care	Name and Location

D. Other Child Care Agency	Name and Location