| Data Element Name: | Term Newborn | ||||||
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| Collected For: | PC-05 | ||||||
| Definition: | Documentation that the newborn was at term or >= 37 completed weeks of gestation at the time of birth. | ||||||
| Suggested Data Collection Question: | Is there documentation that the newborn was at term or >= 37 completed weeks of gestation at the time of birth? | ||||||
| Format: |
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| Allowable Values: |
Y (Yes) There is documentation that the newborn was at term or >= 37 completed weeks of gestation at the time of birth. N (No) There is no documentation that the newborn was at term or >= 37 completed weeks of gestation at the time of birth OR unable to determine from medical record documentation. | ||||||
| Notes for Abstraction: | Gestational age should be rounded off to the nearest completed week, not the following week. For example, an infant born on the 5th day of the 36th week (35 weeks and 5/7 days) is at a gestational age of 35 weeks, not 36 weeks. Estimated gestational age (EGA) may be used to determine gestational age, including a range of numbers that are 37 weeks or greater, e.g., 37-38 weeks gestation.
It is acceptable to use data derived from vital records reports received from state or local departments of public health, delivery logs or clinical information systems if they are available and are directly derived from the medical record with a process in place to confirm their accuracy. If this is the case, these may be used in lieu of the acceptable data sources listed below. The mother's medical record ALONE cannot be used to determine the newborn's gestational age. This documentation must appear in the newborn's medical record without using the mother’s medical record to perform the abstraction even if there is a link between the mother and newborn medical records in the EHR. In cases when there is conflicting documentation, e.g., both term and a gestational age of 36 weeks are documented, the gestational age takes precedence. In cases where there are two different values documented for gestational age and one is determined by examination and the other is determined by the best obstetrical estimate (OE) based on dates, abstract the value determined by dates. | ||||||
| Suggested Data Sources: |
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| Additional Notes: | |||||||
| Guidelines for Abstraction: | |||||||
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