National Vital Statistics System

15. Infections present and/or treated during this pregnancy

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Category: Prenatal Care and Pregnancy History

BC # 42

15. Infections present …
Definitions

Infections present at the time of the pregnancy diagnosis or a confirmed diagnosis during the pregnancy with or without documentation of treatment.

Documentation of treatment during this pregnancy is adequate if a definitive diagnosis is not present in the available record.
Instructions

Check all boxes that apply.  The mother may have more than one infection.

If the mother has none of the risk factors, check “none of the above.”
Sources See below
Keywords and Abbreviations “+” indicates that the test for the infection was positive and the woman has the infection.

“–” indicates that the test was negative, and the woman does not have the infection.

Look for: treatment or Rx for specific infection.
Gonorrhea
Definitions A positive test or culture for Neisseria gonorrhoeae.
Instructions
Sources 1st  Prenatal record under –
  • Infection history
  • Sexually transmitted diseases
  • Problem list
  • Complications this pregnancy
  • Factors this pregnancy
  • Medical history

2nd  Labor and delivery nursing admission triage form under – Comments

3rd Admission history and physical (H&P) under –

  • Current pregnancy history
  • Medical history
  • Problem list/findings

4th Delivery record under –

  • Maternal OB/labor summary
  • Labor and delivery admission history
Keywords and Abbreviations

GC

Gonorrheal

Gonoccocal

Treatment or Rx for Gonocchea

NAAT–Nucleic amplification tests
Syphilis (also called lues)
Definitions A positive test for Treponema pallidum.
Instructions
Sources 1st  Prenatal record under –
  • Infection history
  • Sexually transmitted diseases
  • Problem list
  • Complications this pregnancy
  • Factors this pregnancy
  • Medical history

2nd  Labor and delivery nursing admission triage form under – Comments

3rd Admission history and physical (H&P) under –

  • Current pregnancy history
  • Medical history
  • Problem list/findings

4th Delivery record under –

  • Maternal OB/labor summary
  • Labor and delivery admission history
Keywords and Abbreviations

TP-PA–T. pallidum particle agglutination

STS–Serologic test for syphilis

RPR–Rapid plasma regain

VDRL–Venereal disease research laboratories

FTA-AS–Fluorescent antibody test

Lues

Treatment or Rx for syphilis or lues
Chlamydia
Definitions A positive test for Chlamydia trachomatis.
Instructions
Sources 1st  Prenatal record under –
  • Infection history
  • Sexually transmitted diseases
  • Problem list
  • Complications this pregnancy
  • Factors this pregnancy
  • Medical history

2nd  Labor and delivery nursing admission triage form under – Comments

3rd Admission history and physical (H&P) under –

  • Current pregnancy history
  • Medical history
  • Problem list/findings

4th Delivery record under –

  • Maternal OB/labor summary
  • Labor and delivery admission history
Keywords and Abbreviations

Treatment or Rx for chlamydia
Hepatitis B (HBV, serum hepatitis)
Definitions A positive test for the hepatitis B
Instructions
Sources 1st  Prenatal record under –
  • Infection history
  • Sexually transmitted diseases
  • Problem list
  • Complications this pregnancy
  • Factors this pregnancy
  • Medical history

2nd  Labor and delivery nursing admission triage form under – Comments

3rd Admission history and physical (H&P) under –

  • Current pregnancy history
  • Medical history
  • Problem list/findings

4th Delivery record under –

  • Maternal OB/labor summary
  • Labor and delivery admission history
Keywords and Abbreviations

Hep B

HBV

Treatment or Rx for hepatitis B
Hepatitis C (non A or non B hepatitis [HCV])
Definitions A positive test for the hepatitis C virus
Instructions
Sources 1st  Prenatal record under –
  • Infection history
  • Sexually transmitted diseases
  • Problem list
  • Complications this pregnancy
  • Factors this pregnancy
  • Medical history

2nd  Labor and delivery nursing admission triage form under – Comments

3rd Admission history and physical (H&P) under –

  • Current pregnancy history
  • Medical history
  • Problem list/findings

4th Delivery record under –

  • Maternal OB/labor summary
  • Labor and delivery admission history
Keywords and Abbreviations

Hep C

HCV

Treatment or Rx for hepatitis C

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