PPS Newborn Data Collection Form,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,

,,Chapter:,CENTRAL LUZON,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Hospital ID,III-3,Hospital name,CENTRAL LUZON DOCTORS HOSPITAL,,,,,,,Month/Year,23-
Mar,No. of Live Births,14,No. of Discharges,12,No. of Deaths,2,,,,,,,,,,,,,,,,,,,,
Patients No.,Patient's Initial,Date of Admission (MM/DD/YYYY),Maturity: 0-Full
Term(37W-41W). 1-Extremely PreTerm(27 and below). 2-Very PreTerm(28W-31W). 3-
Moderate and Late Preterm (32W-36W). 4-Post term (42 weeks and above).,Gestational
Age (Weeks),Weight (Grams),Weight for Gestational Age 0 = SGA. 1 = AGA. 2 =
LGA,Presentation 0 = Cephalic. 1 = Breech. 2 = Transverse,Manner of Delivery 0 =
SVD. 1 = Forceps. 2 = CS. 3 = Vacuum. 4 = Breech Extraction,Sex 0 = Male. 1 =
Female. 2 = Ambiguous,"Apgar Score (0-9, 0-9, 0-9)",EINC: 0 - Completed 4 core
steps. 1 - Incomplete. 2 - Not Done,Incomplete EINC Steps. 1-Immediate and thorough
drying. 2-Skin to skin contact. 3-Properly timed cord clamping. 4-Non separation of
the mother and baby,Diagnosis 1: Number and place of birth 0=singleton-in hospital
1=singleton-outside hospital 2=twin-in hospital 3=twin-outside hospital 4=multiple-
in hospital,No. of fetuses (0-4),Patient Birth Location: 0 - Inborn. 1 -
Outborn. 2 - Readmission(Up to 28 days),ICD no. 1 (Number and place of birth) 0=
Z38.0 1=Z38.1 2=Z38.3 3=Z38.4 4=Z38.6,Diagnosis 2: Hyperbiliribunemia 0 - none. 1 =
physiologic. 2 = breastfeeding. 3 = ABO incompatibility. 4 = prematurity 5 = other
causes (free text),ICD no. 2 (Hyperbilirubinemia) 1 or 2 = P59.9 3 = P55.1 4 =
P55.0 5 = must write ICD no.,Highest Total Bilirubin level (mg/dL) and age in days.
Indicate highest bilirubin level reached (actual serum bilirubin in mg/dL) and day
of life,Diagnosis 3: Respiratory 0 - normal lungs. 1 = TTN . 2 = RDS. 3 =
Pneumonia,ICD no.3 (Respiratory) 1 = P22.1. 2 = P22.0. 3 = P23.9 4 = P21 ( write
the correct ICD no.),Respiratory support: 0-IPPV. 1-NIPPV. 2-Nasal CPAP. 3-Nasal
High Flow. 4-Face mask. 5-Nasal Cannula. 6-Blow by oxygen,Diagnosis 4: Sepsis 0 -
none. 1 - Clinical Sepsis 2 - Culture Proven,ICD no.4 (Sepsis) 1 - P36 2 = (must
write ICD no.),Diagnosis 5: Asphyxia 0 - No. 1 - Yes,ICD no.5 (Asphyxia) 1 - (must
write ICD No.),Diagnosis 6: Congenital Diseases Write the diagnosis,ICD no.6 (write
corresponding ICD no.),Diagnosis 7: Others,ICD no.7 (write corresponding ICD
no.),Baby's COVID status. 0 - RTPCR Negative. 1 - RTPCR Positive Asymptomatic. 2 -
Positive Mild. 3 - Positive Severe . 4 - Positive Critical. 5 - Unknown,Mother's
COVID status. 0 - Covid Negative. 1 - RTPCR Positive. 2 - RAT Positive. 3 -
Unknown,Kangaroo Mother Care (KMC) at the time of discharge: 0 - intermittent(< 20
hours). 1 - continuous (KMC ward or > 20 hours). 2 - not enrolled,Type of Feeding
on Discharge. 0 - Exclusive Breastmilk. 1 - Mixed Feeding. 2 - Formula. 3 - None
(Baby Died),Use of Donor Human Milk. 0 - No. 1 - Pasteurized Human Milk. 2 -
Unpasteurized Human Milk,Discharge outcome Live/Dead,Date Discharged (MM/DD/YYYY)
1,TY,3/11/2023,0,39,3100,1,0,2,1,8
9,0,,0,1,1,Z38.1,0,,,0,,,0,,0,,,,,,0,0,2,1,0,Live,3/22/2023
2,AJ,3/15/2023,0,39,3400,1,0,2,1,9
9,0,,0,1,0,Z38.0,0,,,0,,,0,,0,,,,,,0,0,2,1,0,Live,3/17/2023
3,TR,3/7/2023,1,29,1350,1,0,2,1,7
8,0,,0,1,0,Z38.0,0,,,2,,0,0,,0,,,,,,0,0,2,1,0,DEAD,6/11/2022
4,FA,3/24/2023,0,38,2500,1,0,2,1,8
9,0,,0,1,1,Z38.0,0,,,3,,1,0,,0,,,,,,0,0,2,1,0,Live,4/3/2023
5,MR,3/28/2023,0,37,3430,1,0,0,0,8
9,0,,0,1,0,Z38.0,0,,,0,,,0,,0,,,,,,0,0,2,1,0,Live,4/14/2023
6,SR,3/18/2023,0,41,3140,1,0,2,0,8
9,0,,0,1,0,Z38.0,0,,,0,,,0,,0,,,,,,0,0,2,1,0,Live,3/19/2023
7,FT,3/18/2023,0,38,2660,1,0,2,1,8
9,0,,0,1,0,Z38.0,0,,,0,,,0,,0,,,,,,0,0,2,1,0,Live,3/20/2023
8,BJ,3/19/2023,0,38,1600,0,0,2,0,2 6 9,1,2 3
4,0,1,0,Z38.0,0,,,0,,,1,P36,0,,,,,,0,0,2,1,0,DEAD,3/29/2023
9,MA,3/20/2023,0,38,3000,1,0,2,0,8
9,0,,0,1,0,Z38.0,0,,,0,,,0,,0,,,,,,0,0,2,1,0,Live,3/22/2023
10,LJ,3/20/2023,3,37,1900,1,2,2,0,8
9,2,4,2,2,1,Z38.1,0,,,0,,,0,,0,,,,,,0,0,2,1,0,Live,3/22/2023
11,CG,3/20/2023,0,37,2810,1,0,2,1,8
9,0,4,1,1,1,Z38.0,0,,,0,,,0,,0,,,,,,0,0,2,1,0,Live,3/22/2023
12,MC,3/24/2023,3,36,3000,1,1,2,1,8
9,0,,1,1,1,Z38.1,0,,,0,,,1,,0,,,,,,0,0,2,1,0,Live,3/26/2023
13,BV,3/30/2023,0,37,2900,1,0,2,1,8
9,0,,1,1,1,Z38.0,0,,,0,,,0,,0,,,,,,0,0,2,1,0,Live,4/1/2023
14,AZ,3/31/2023,0,37,2600,1,0,2,1,8
9,0,,1,1,1,Z38.1,0,,,0,P23.9,,0,,0,,,,,,0,0,2,1,0,Live,4/8/2023