| Name: | Previous Live Births | ||||||
|---|---|---|---|---|---|---|---|
| Collected For: | PC-02 | ||||||
| Definition: | Documentation that the patient experienced a live birth prior to the current hospitalization. | ||||||
| Question: | Did the patient experience a live birth prior to the current hospitalization? | ||||||
| Format: |
| ||||||
| Allowable Values: |
Y (Yes) There is documentation that the patient experienced one or more live births prior to the current hospitalization. N (No) There is no documentation that the patient experienced one or more live births prior to the current hospitalization OR unable to determine from medical record documentation. | ||||||
| Notes for Abstraction: |
The delivery or operating room record should be reviewed first for documentation of previous live births. If documentation of previous live births is not present or is conflicting in the delivery or operating room record, then continue to review the acceptable data sources in the following order: history and physical, clinician admission progress note, prenatal forms, and discharge summary until a positive finding for previous live births is found.
If there is conflicting documentation throughout the acceptable sources and it cannot be determined from the medical record if there were previous live births, select No. Documentation in the acceptable data sources may be written by the following clinicians:
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 Only Acceptable Sources listed below. Parity may be used in the absence of documentation of the number of previous live births. If the number for parity documented is "one" and includes the delivery for the current hospitalization, do not include the current delivery to determine previous live births. A string of three or more numbers without the alpha designation of "p" preceding the second number cannot be used to determine parity. Example: 321 When GTPAL terminology is documented, G= Gravida, T= Term, P= Preterm, A= Abortions, L= Living, P does not equal parity. | ||||||
| Suggested Data Sources: |
ONLY ACCEPTABLE SOURCES IN ORDER OF PREFERENCE:
| ||||||
| Additional Notes: | |||||||
| Guidelines for Abstraction: | |||||||
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