pre-registration - royal berkshire hospital · hb electrophoresis . comments . name m number 5 ....

CMIS HD Clinical Business Continuity Document

V3.703 March 2011

BOOKING MODULE PRE-REGISTRATION REGISTRATION Hospital number

Surname

Forenames

Address

Postcode

District of Residence

Date moved to this address

Telephone Number

Mobile Number

NHS Number

Email Address

CARE DETAILS

Booking Status

Referred By

Hospital Referred to

Date Referral received

Patient Category

Date of LMP at Referral

EDD at Referral

Name M number 1


V3.703 March 2011

Gestation

Patient Category NHS Overseas Private

Midwife Team

Consultant

REGISTERED GP

REFERRING GP IF DIFFERENT FROM ABOVE

Name M number 2


V3.703 March 2011

BOOK SUMMARY KEY BOOKING DATA Date of Birth

Martial Status

Ethnic Group

Interpreter needed

Certainty of LMP

Date of LMP

Provisional EDD

Menstrual Cycle

Length of cycle

Date of first antenatal assessment

Gestation at booking

Age at booking Medical history

Smoking status at booking

Smoker Smoker now stopped Referred to stop smoking services Declined stop smoking services

Partner smoker

Diabetes

Epilepsy

Hypertension

Blood Transfusions

Other booking complications

Name M number 3


V3.703 March 2011

Comments

OBSTETRIC HISTORY

Parity

Previous Livebirths

Previous Stillbirths

Previous deaths within 28 days

Previous Miscarriages

Previous terminations

Number of previous LSCS

Other booking data

Height

Weight at booking

BP at booking

Proposed place of birth

Type of care

Next antenatal appointment

Name M number 4


V3.703 March 2011

ANTENATAL

INVESTIGATIONS Date blood sample was taken

ABO

Rhesus

HB

Antibodies

TPHA

Sickle cell

Rubella

Immune Not immune

Partners HB

Partners Sickle cell

CX smear

Diabetic screen

Hepatitis antigen

HB electrophoresis

Comments

Name M number 5


V3.703 March 2011

SCREENING HIV screening

Folic Acid

When started weeks

Preconception

Post-conception

Downs Screening

Number of fetuses

Antenatal screening

Accepted Declined

Method of screening undertaken

1st Trimester screening

Date Nuchal fold scan

Date biochemical screening

Overall risk

2nd Trimester screening

Date biochemical screening

Overall risk

Diagnostic testing

Number of fetuses

Diagnostic testing

Accepted declined not required

Method of testing carried out

Name M number 6


V3.703 March 2011

ULTRASOUND

Date of EDD by ultrasound

Working Edd

Date of scan for this determination

Biparietal diameter

Anomaly scan

Done not done abnormality detected

Date anomaly scan

Name M number 7


V3.703 March 2011

INVESTIGATIONS

AN COMPLICATIONS 1

Renal disease

Cholestasis

Impaired glucose tolerance test

UTI

Cardiac

BP max diastolic on more than one occasion

Proteinuria

AN COMPLICATIONS 2

APH

Blood transfusion

Medication

Cervical suture

Other antenatal complications

Name M number 8


V3.703 March 2011

FURTHER ANTENATAL DETAILS Weight last clinic visit

Haemoglobin lowest value

Number of ultrasounds

Number of antenatal visits

Antenatal management

Smoking status Smoker Smoker now stopped Referred to stop smoking services Declined stop smoking services

Does partner smoke

How many does partner smoke

Name M number 9


V3.703 March 2011

ANTENATAL ADMISSION

Date of admission

Time of admission

Ward

Method of admission

Source of admission

Patient category

Midwife team

Consultant

Specialty

TRANSFER

Date of Transfer

Time of Transfer

Ward

Patient Category

Midwife Team

Consultant

Named Midwife

Specialty DISCHARGE (A/N)

Name M number 10


V3.703 March 2011

Discharge Date

Discharge Time

Method

Destination

Spell Status

DIAGNOSIS

Diagnosis (antenatal)

Operation (Antenatal)

Name M number 11


V3.703 March 2011

POSTNATAL READMISSION

Date

Time

Ward

Method

Source

Patient Category

Midwife Team

Consultant

Specialty Obstetrics TRANSFER

Date of Transfer

Time of Transfer

Ward

Patient Category

Midwife Team

Consultant

Specialty DISCHARGE (A/N)

Name M number 12


V3.703 March 2011

Discharge Date

Discharge Time

Method

Destination

DIAGNOSIS

Diagnosis (antenatal)

Operation (Antenatal)

Name M number 13


V3.703 March 2011

DELIVERY LABOUR Number of Infants this Delivery

One Parent Family

Labour Onset

Augmentation

Onset of First Stage – date

Onset of First Stage – time

Onset of Second Stage – date

Onset of Second Stage – time

CARE ICP Care ICP for normal labour used

Transfer in labour

Reason if transferred

Transfer post delivery

ANALGESIA Labour

Delivery

Post Delivery

Was anaesthetic assistance sought

DELIVERY 1 Maximum temp in labour

Name M number 14


V3.703 March 2011

Blood Loss (mls)

Perineum

Non-Perineal Tear

Tear Sutured

Care at delivery

DELIVERY 2 Manual Removal

Placenta

Membranes

Other Complications

Method of Feeding

Breast feeding initiated

Date of first breast feed

Time of first breastfeed

Skin to Skin contact

Explain no skin to skin contact

Name M number 15


V3.703 March 2011

TRANSFER (post delivery) Admission ward for Delivery

Date

Time

Ward transferred Post Delivery

Date

Time

Category

Midwife Team

Consultant

Specialty

Name M number 16


V3.703 March 2011

THE INFANT IN UTERO Rupture of Membranes

Rupture Date

Rupture Time

Cord Prolapse

ECV before Labour

Not required Unsucessful Sucessful

Electronic Fetal Heart Monitoring

Intermittant auscultation

Lowest Fetal pH

Meconium

Cord Blood gases

Venous PH

Venous Base Deficit

Arterial PH

Arterial Base Deficit

BIRTH 1 Date of birth

Time

Sex

Placenta Delivery time

Management of third stage

Gestation

Name M number 17


V3.703 March 2011

Third stage duration

Management

Birthweight (gms)

Centile

Congenital Malformations

Birthing Pool

Presentation at Delivery

Method of Delivery

Indication for Instrumental delivery

Outcome

Shoulder dystocia

Injury (comment)

BIRTH 2

Place of Delivery

Name M number 18


V3.703 March 2011

Person Conducting Delivery

Midwife responsible for delivery :

Surname

Initial

Status

Midwife Team

Midwife known to Mum

Name M number 19


V3.703 March 2011

INFANT REGISTRATION Infant NHS number

Surname

Forenames

Ethnic Origin

Consultant Paediatrician

INFANT DETAILS Apgar @ 1 minute

Apgar @ 5 minutes

Onset of Regular Respiration

Resusitation (Positive Pressure)

Resusitation Drugs

Vtamin K

Other Complications – specify

Child’s Address on Discharge

TRANSFER (after birth)

Transfer to Date

Time

Ward

Patient Category

Consultant

Specialty

Name M number 20


V3.703 March 2011

DISCHARGE (Mother)

COMPLICATIONS at any time

Eclampsia

Thromboembolism

E.R.P.C.

Puerperal Psychosis

Other Complications

Infections

Discharge 1

Haemoglobin

Haemoglobin gm/dl

Anti-D

Rubella vaccination

Blood transfusion

Proposed contraception

Postnatal care

This Trust Other

Postnatal appointment

Medication on Discharge

Smoking at discharge Smoker Smoker now stopped Referred to stop smoking services Declined stop smoking services

DISCHARGE

Name M number 21


V3.703 March 2011

Discharge date

Time

Method

Destination

Discharged by

First name

Surname

Status

Comments

Name M number 22


V3.703 March 2011

NEONATAL DETAILS BIRTH SUMMARY Paediatric assessment of gestation

Birth weight

Birth head circumference

Birth Length

Consultant Paediatrician EXAMINATIONS Hip examination

Convulsions

Other Abnormal Behaviour

Jaundice

Other Infant Complications

Congenital Abnormalities

INVESTIGATIONS Cord

Guthrie/hypothyroidism test

Haemoglobinopathy/Sickle trait

Vitamin K

Hearing test

Name M number 23


V3.703 March 2011

DISCHARGE CONDITION

Highest level of care

NICU/SCBU

Transitional care.

Discharge examination

Present condition of infant

Comments

Vaccinnations Outstanding results

Vaccination required before discharge

Vaccinations

Pertussis Immunisation

BCG vaccination

Date given

Meningitis C

Hepatitis B

Other vaccinations

DISCHARGE 1 Weight at discharge

Length at discharge

Feeding mode

Feeding type

Name M number 24


V3.703 March 2011

Name M number 25

Latest results

DISCHARGE 2 Date of discharge

Time of discharge

Method of discharge

Destination

FOLLOW UP

Follow up appointment

Follow up investigations

pre-registration - royal berkshire hospital · hb electrophoresis . comments . name m number 5 ....

Documents