Free 52236.pdf - Indiana

ANNUAL BIRTHING CENTER REPORT
State Form 52236 (7-05)

Indiana State Department of Health-Division of Acute Care (Pursuant to IC 16-21-2 and 410 IAC 27)

INSTRUCTIONS:
1. Complete the birthing center location information. (Note: The first annual report may be less than a twelve (12) month period since the application for renewal is due one month prior to expiration. The second and subsequent years will be twelve-month periods. Example: Initial license was effective June 1, 20x1. Renewal application is due May 1, 20x2. The first report will be for the period beginning June 1, 20x1and ending March 31, 20x2. The second report will be for the period beginning April 1, 20x2 and ending March 31, 20x3. All subsequent reports will be for the period April 1 through March 31.) 2. Using the definitions and guidance given, complete items A through V on the reverse side. 3. Enclose this report with the application for license to operate a birthing center (State Form 52235).

Birthing Center Location
Name of Birthing Center

Street Address

P.O. Box

City

County

Zip Code +4

Telephone Number ( )

Fax Number ( )

Reporting Period: Beginning: __________, 1, _____ Month Year Ending: __________, ____, _____ Month Day Year

Name of person completing this form: Email of person completing this form:

Definitions: Attrition: transfer to an alternative site because delivery is not expected after 20 weeks or for a non-medical reason. Enrollment: Client deemed by a qualified provider to be medically appropriate for delivery in a birthing center and has consented to deliver at the center. Intrapartum Admission: A mother in labor deemed by a qualified provider to be medically appropriate for delivery at the center. Referral: non-urgent, non-emergency transfer during any period. Transfer: a change in delivery site from the birthing center to an alternative site. Transport: any emergency transfer.

Item

Number

A. Total Enrollments: B. Total Admissions: C. Total Medicaid Admissions: D. Total Client Attrition (clients that left the center during pregnancy for any reason): E. Non-medical Attrition (clients that left the center during pregnancy for non-medical reasons): F. Medical Attrition (clients that left the center during pregnancy for medical reasons): G. Pre-admission Intrapartum Referrals (referral to an alternative site upon initial evaluation or prior to an in-labor admission): H. Intrapartum Referrals (in-labor referral after admission but prior to delivery): I. Emergency Intrapartum Transports (transfer to an alternative site using emergency transport): J. Postpartum Referrals (non-urgent, non-emergency referral to another care system): K. Emergency Postpartum Transport (transfer to an alternative site using emergency transport): L. Newborn Referrals (non-urgent, non-emergency referral to another care system): M. Emergency Newborn Transports (transfer to an alternative site using emergency transport): N. Re-admissions (hospitalization of mother within 6 weeks for a pregnancy related complication or the infant within 7 days of age. O. Births in the center: P. Spontaneous vaginal births: Q. C-sections: R: Fetal deaths: S: Newborn deaths in the center: T: Newborn deaths occurring after transfer: U: Newborn deaths at home: V: Maternal deaths: