MOD Big 5 ACT Data Collection Form for Live-born Infants
The MOD Big 5 ACT Data Collection Form is designed for recording data of live-born infants delivered at or between 23 and 33 weeks of gestational age. Complete this form for the first live-born baby delivered in case of multiple deliveries. The form collects essential details including mother's race, primary payment source, and details of any ACT medication given.
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How do I fill this out?
To fill out this form, gather all necessary information from medical records and patient interactions. Ensure accuracy in details like gestational age, maternal race, and ACT medication history. Follow the instructions provided for each section to complete the form.
How to fill out the MOD Big 5 ACT Data Collection Form for Live-born Infants?
1
Start by gathering all required patient information from medical records.
2
Fill in the details about the mother's race, primary payment source, and arrival date/time at the hospital.
3
Record the baby's birth date/time and mother's parity prior to birth.
4
Document gestational age at delivery and the method used for confirmation.
5
Ensure all ACT medication information is accurately recorded by following the specified queries.
Who needs the MOD Big 5 ACT Data Collection Form for Live-born Infants?
1
Healthcare providers to record essential data of live-born infants.
2
Hospital administrators for maintaining accurate records of deliveries.
3
Researchers to gather data for studies involving live-born infants.
4
Insurance companies to verify primary payment sources and medical history.
5
Public health officials to monitor and improve neonatal care practices.
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What are the instructions for submitting this form?
Submit the completed MOD Big 5 ACT Data Collection Form via the following methods: Email: submit@hospital.org Fax: (123) 456-7890 Online: www.hospital.org/submissions Physical Address: Hospital Records Department, 123 Healthcare Lane, City, State, ZIP Code. Ensure all sections are accurately completed before submission to maintain precise and valuable records.
What are the important dates for this form in 2024 and 2025?
The MOD Big 5 ACT Data Collection Form should be submitted promptly after the delivery of live-born infants. Ensure submissions are made in 2024 and 2025 as applicable for record-keeping and compliance purposes.
What is the purpose of this form?
The MOD Big 5 ACT Data Collection Form is designed to gather essential data related to live-born infants delivered at or between 23 and 33 weeks of gestational age. This form is crucial for recording maternal and infant medical history, including details about race, payment sources, and administration of ACT medication. It helps healthcare providers, administrators, and researchers maintain accurate records and contribute to neonatal care improvements. Additionally, the form collects vital information that can be used for studies, insurance verification, and public health monitoring. By completing this form, you ensure that all pertinent data is documented, supporting better healthcare outcomes for infants and mothers. The form serves as a standardized method for collecting and analyzing data related to preterm births, aiding in the identification of trends and the formulation of targeted interventions.
Tell me about this form and its components and fields line-by-line.
- 1. Hospital ID: The unique identifier for the hospital where the delivery took place.
- 2. Case ID: The unique case number associated with the patient's record.
- 3. Mother's Race/Ethnicity: Select the race/ethnicity of the mother from the given options.
- 4. Primary Payment Source: The main payment source listed in the medical record for the delivery.
- 5. Mother's Arrival Date/Time: Record the date and time when the mother arrived at the delivering hospital.
- 6. Baby's Birth Date/Time: Record the date and time when the baby was born.
- 7. Mother's Parity: Number of term births, preterm births, and abortions prior to this delivery.
- 8. Gestational Age at Delivery: The number of weeks and days of gestational age at the time of delivery.
- 9. Gestational Age Confirmation: Method used to determine or confirm gestational age.
- 10. Reason for Preterm Birth: The primary reason for the preterm birth from the given options.
- 11. ACT Medication Prior to Delivery: Whether the mother received any ACT medication before this delivery admission.
- 12. ACT Medication During Delivery Admission: Whether the mother received any ACT medication during this delivery admission.
- 13. Referral for Delivery Admission: Details about any referrals made prior to the delivery hospital admission.
- 14. Reason ACT Not Given: Reasons why ACT medication was not given during the delivery admission.
- 15. 1st ACT Injection Location: Location where the first ACT injection was administered during the first course.
- 16. 1st ACT Injection Date/Time: Date and time when the first ACT injection was given.
- 17. Complete 1st ACT Course: Whether a complete first ACT course was given.
- 18. 2nd ACT Course Given: Whether a second partial or full ACT course was given.
- 19. 2nd ACT Injection Location: Location where the first ACT injection was administered during the second course.
- 20. 2nd ACT Injection Date/Time: Date and time when the first ACT injection was given for the second course.
- 21. Additional ACT Injections: Whether any additional ACT injections were given after completing the second course.
- 22. Mother's Age: The age of the mother in years.
- 23. Length of Stay: Whether the mother's length of stay in the hospital was greater than 120 days.
- 24. Research Clinical Trial Enrollment: Whether the mother was enrolled in a research clinical trial.
What happens if I fail to submit this form?
Failure to submit this form might result in incomplete medical records, affecting patient care and data accuracy.
- Incomplete Records: Healthcare providers may not have access to complete medical information, impacting patient care.
- Data Accuracy: Missing data can affect the overall accuracy of records and subsequent analysis for research or clinical purposes.
How do I know when to use this form?
- 1. Live-born Infants: Record data for infants delivered live within the specified gestational age.
- 2. Multiple Deliveries: Complete one form for the first live-born baby in cases of multiple deliveries.
- 3. ACT Medication: Document the administration of ACT medication before and during delivery admission.
- 4. Hospital Admissions: Provide details about the mother's arrival and referral for hospital admission.
- 5. Gestational Age Confirmation: Record the method used to determine or confirm gestational age at delivery.
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