PPS Newborn Data Collection Form

Chapter:
Hospital ID _____VI-9 Hospital name

Patients No. Patient's Initial Date of Admission (MM/DD/YYYY)

1 A.,M.A. 8/1/2023
2 V.,A.C. 8/1/2023
3 C.,G. 8/1/2023
4 T.,G. 8/2/2023
5 L.,K.A. 8/2/2023
6 D.,A.L. 8/2/2023
7 C.,L.C. 8/2/2023
8 T.,J. 8/3/2023
9 F.,N.M. 8/3/2023
10 C.,J. 8/3/2023
11 J.,G. 8/4/2023
12 R.,M.J. 8/6/2023
13 I.,H. 8/7/2023
14 N.,R. 8/7/2023
15 L.,S.M. 8/7/2023
16 O.,R. 8/8/2023
17 L.,L. 8/8/2023
18 E.,S. 8/9/2023
19 C.,E. 8/11/2023
20 E.,M. 8/11/2023
21 B.,N. 8/13/2023
22 B.,A. 8/15/2023
23 A.,H. 8/17/2023
24 P.,M. 8/18/2023
25 G.,J. 8/18/2023
26 M.,G. 8/20/2023
27 D., J. 8/22/2023
28 E.,O. 8/22/2023
29 P.,C. 8/23/2023
30 G.,J. 8/24/2023
31 E.,K. 8/25/2023
32 A.,L 8/26/2023
33 A.,C 8/26/2023
34 Q.,E. 8/26/2023
35 R.,C. 7/29/2023
36 G.,D. 28-Jul
37 M.,K. 7/29/2023
38 O.,D 7/25/2023
39 P.,W. 7/31/2023
_____Central Visayas
_____Southwestern University-Medical Center

Maturity: 0-Full Term(37W-41W). 1-Extremely PreTerm(27 and below). 2-Very PreTerm(28W-31W). 3-

0
0
0
0
0
0
3
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
Gestational Age (Weeks) Weight (Grams)
39 3,405
38 3,605
38 3,550
39 3,430
38 2,740
39 2,735
35 2,350
39 3,155
39 3,555
39 3,575
39 2,705
39 3,345
39 3,995
37 3,275
39 2,835
38 2,855
39 2,710
39 3,440
39 3,380
39 2,835
40 3,175
40 3,435
40 2,925
38 3,025
39 2,915
40 4, 400
37 2, 950
40 2, 845
40 3,925
39 3,160
39 3, 305
39 3, 505
39 3, 305
37 2, 910
39 2,445
39 2760
39 3,165
39 2, 960
39 3, 150
Weight for Gestational Age 0 = SGA. 1 = AGA. 2 = LGA
1
2
1
1
1
1
1
1
1
1
1
1
2
1
1
1
1
1
1
1
1
1
1
1
1
2
1
1
1
1
1
1
1
0
1
1
1
1
1
Presentation 0 = Cephalic. 1 = Breech. 2 = Transverse
1
0
1
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
Manner of Delivery 0 = SVD. 1 = Forceps. 2 = CS. 3 = Vacuum. 4 = Breech Extraction
2
2
2
0
0
0
2
0
2
0
0
2
2
0
2
0
0
2
2
0
0
0
2
2
0
2
2
0
2
2
0
0
0
0
2
2
2
0
0
 Month/Year:

Sex 0 = Male. 1 = Female. 2 = AmbiguousApgar Score (0-9, 0-9, 0-9)

1 9,9
0 9,9
1 9,9
0 9,9
1 7,8,9
0 9,9
1 7,9
0 9,9
0 9,9
0 9,9
1 9,9
1 9,9
0 9,9
1 9,9
0 9,9
1 9,9
0 6,7,9
1 7,9
1 9,9
0 9,9
0 6,9
0 8,9
1 8,9
0 8,9
1 9,9
1 8, 9
0 7, 9
1 9, 9
0 9, 9
0 9, 9
1 9, 10
0 9, 9
1 7, 9
0 8, 9
1 9, 9
0 8, 9
1 9, 9
1 8, 9
0 9, 9
 Aug-23

EINC: 0 - Completed 4 core steps. 1 - Incomplete. 2 - Not Done

1
1
1
0
0
0
1
0
1
0
0
1
1
0
1
0
1
1
1
0
1
0
1
1
0
1
1
0
1
1
0
0
0
0
1
1
1
0
0
No. of Live Births

Incomplete EINC Steps. 1-Immediate and thorough drying. 2-Skin to skin contact. 3-Properly timed
1
1
1

1
1

1
1
1

1
1

1
1

1
1

1
1
1
_____39

Diagnosis 1: Number and place of birth 0=singleton-in hospital 1=singleton-outside hospital 2=twin-
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
No. of Discharges

No. of fetuses (0-4)

1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
 _____39

Patient Birth Location: 0 - Inborn. 1 - Outborn. 2 - Readmission(Up to 28 days)

0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
No. of Deaths

ICD no. 1 (Number and place of birth) 0= Z38.0 1=Z38.1 2=Z38.3 3=Z38.4 4=Z38.6
Z38.0
Z38.0
Z38.0
Z38.0
Z38.0
Z38.0
Z38.0
Z38.0
Z38.0
Z38.0
Z38.0
Z38.0
Z38.0
Z38.0
Z38.0
Z38.0
Z38.0
Z38.0
Z38.0
Z38.0
Z38.0
Z38.0
Z38.0
Z38.0
Z38.0
Z38.0
Z38.0
Z38.0
Z38.0
Z38.0
Z38.0
Z38.0
Z38.0
Z38.0
Z38.0
Z38.0
Z38.0
Z38.0
Z38.0
 _____0

Diagnosis 2: Hyperbiliribunemia 0 - none. 1 = physiologic. 2 = breastfeeding. 3 = ABO incompatibility

0
0
0
Sepsis
0
0
4
0
0
0
0
0
0
0
0
0
0
0
0
Sepsis
0
0
0
2
0
0
0
0
0
0
0
0
0
0
0
1
0
1
0
ICD no. 2 (Hyperbilirubinemia) 1 or 2 = P59.9 3 = P55.1 4 = P55.0 5 = must write ICD no.

P58.2

P55.0

P58.2

P59.9

P59.9

P59.9
Highest Total Bilirubin level (mg/dL) and age in days. Indicate highest bilirubin level reached (actua

8.30 mg/dL on day 3

6.80 mg/dL on day 3

17.52 mg/dL on day 5

9.23 mg/dL on day 3

9.54 mg/dL on day 3

8.81 mg/dL on day 2

Diagnosis 3: Respiratory 0 - normal lungs. 1 = TTN . 2 = RDS. 3 = Pneumonia
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
1
0
0
0
0
0
3
1
0
0
0
0
0
0
0
0
0
0
0
0
ICD no.3 (Respiratory) 1 = P22.1. 2 = P22.0. 3 = P23.9 4 = P21 ( write the correct ICD no.)

P22.1

P23.9
P22.1
Respiratory support: 0-IPPV. 1-NIPPV. 2-Nasal CPAP. 3-Nasal High Flow. 4-Face mask. 5-Nasal Cannul

5
5
Diagnosis 4: Sepsis 0 - none. 1 - Clinical Sepsis 2 - Culture Proven
0
0
0
1
0
0
1
0
1
0
1
0
0
0
0
0
1
1
0
1
1
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
1
ICD no.4 (Sepsis) 1 - P36 2 = (must write ICD no.)
Diagnosis 5: Asphyxia 0 - No. 1 - Yes
0
0
0
P36 0
0
0
P36 0
0
P36 0
0
P36 0
0
0
0
0
0
P36 0
P36 0
0
P36 0
P36 0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
P36 0
ICD no.5 (Asphyxia) 1 - (must write ICD No.)
Diagnosis 6: Congenital Diseases Write the diagnosis

Cleft Lip, partial

ICD no.6 (write corresponding ICD no.) Diagnosis 7: Others

Q36.9
Infant of Diabetic Mother
Infant of Diabetic Mother

S/P Circumcision

Infant of Diabetic Mother

Infant of Diabetic Mother

Infant of Diabetic Mother

Infant of Diabetic Mother

Infact of Diabetic Mother

Low Birthweight
ICD no.7 (write corresponding ICD no.)

P70.1
P70.1

Z41.2

P70.1
P70.1

P70.1
P70.1

P70.1

P07.1
Baby's COVID status. 0 - RTPCR Negative. 1 - RTPCR Positive Asymptomatic. 2 - Positive Mild. 3 - Posi
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
Mother's COVID status. 0 - Covid Negative. 1 - RTPCR Positive. 2 - RAT Positive. 3 - Unknown
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
Kangaroo Mother Care (KMC) at the time of discharge: 0 - intermittent(< 20 hours). 1 - continuous (K
2
2
2
2
2
2
1
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
Type of Feeding on Discharge. 0 - Exclusive Breastmilk. 1 - Mixed Feeding. 2 - Formula. 3 - None (Ba
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
Use of Donor Human Milk. 0 - No. 1 - Pasteurized Human Milk. 2 - Unpasteurized Human Milk
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
Discharge outcome Live/Dead Date Discharged (MM/DD/YYYY)
Live 8/6/2023
Live 8/7/2023
Live 8/4/2023
Live 8/9/2023
Live 8/5/2023
Live 8/4/2023
Live 8/18/2023
Live 8/5/2023
Live 8/11/2023
Live 8/6/2023
Live 8/8/2023
Live 8/9/2023
Live 8/10/2023
Live 8/9/2023
Live 8/10/2023
Live 8/9/2023
Live 8/14/2023
Live 8/14/2023
Live 8/14/2023
Live 8/17/2023
Live 8/23/2023
Live 8/19/2023
Live 8/20/2023
Live 8/20/2023
Live 8/21/2023
Live 8/27/2023
Live 8/26/2023
Live 8/24/2023
Live 8/25/2023
Live 8/26/2023
Live 8/27/2023
Live 8/28/2023
Live 8/28/2023
Live 8/30/2023
Live 8/1/2023
Live 8/1/2023
Live 8/2/2023
Live 8/3/2023
Live 8/7/2023