VS-10A MEDICAL
DATA SUPPLEMENTAL WORKSHEET (2005)
VS 10A (1/2005) CERTIFICATE OF LIVE BIRTH—MEDICAL DATA
SUPPLEMENTAL WORKSHEET
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Use the codes on this Worksheet to report the
appropriate entry in items numbered 25D and 28A through 31 on the
“Certificate of Live Birth.” |
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Item 25D. PRINCIPAL
SOURCE OF PAYMENT FOR PRENATAL CARE (Enter only 1 code) |
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02 Medi-Cal,
without CPSP Support Services 13 Medi-Cal, with CPSP Support Services 05 Other
Government Programs (Federal, State, Local) |
07 Private Insurance Company 09 Self Pay 14 Other |
99 Unknown
00 No Prenatal Care |
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Item 28A.
METHOD OF DELIVERY (Enter only 1 code/number under each
section, separated by commas:
A,B,C,D,E)
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A.
Final delivery route
01 Cesarean—primary 11 Cesarean—primary, with trial of labor
attempted 21 Cesarean—primary, with vacuum 31 Cesarean—primary, with vacuum & trial
of labor attempted 02 Cesarean—repeat 12 Cesarean—repeat, with trial of labor
attempted 22 Cesarean—repeat, with vacuum 32 Cesarean—repeat, with vacuum & trial
of labor attempted 03 Vaginal—spontaneous 04 Vaginal—spontaneous, after previous
Cesarean 05 Vaginal—forceps 15 Vaginal—forceps, after previous Cesarean 06 Vaginal—vacuum
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B. If
mother had a previous Cesarean—How
many? _______
(Enter 0 – 9, or U if Unknown)
C.
Fetal presentation at birth
20
Cephalic fetal presentation at delivery 30 Breech fetal presentation
at delivery 40 Other fetal presentation
at delivery 90 Unknown D. Was vaginal delivery
with forceps attempted, but unsuccessful? 50
Yes 58 No
59 Unknown E. Was vaginal delivery
with vacuum attempted, but unsuccessful? 60 Yes
68 No 69
Unknown |
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Item 28B.
EXPECTED PRINCIPAL SOURCE OF PAYMENT FOR DELIVERY (Enter only 1 code) |
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02 Medi-Cal 15 Indian Health
Service 16 CHAMPUS/TRICARE |
05 Other Government Programs (Federal, State,
Local) 07 Private Insurance 09 Self Pay |
14 Other 99 Unknown 00 Medically Unattended Birth |
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Item 29. COMPLICATIONS AND
PROCEDURES OF PREGNANCY AND CONCURRENT ILLNESSES
(Enter up to 16 codes, separated by
commas, for the most important complications/procedures) |
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Item 30. COMPLICATIONS AND PROCEDURES OF LABOR AND DELIVERY
(Enter up to 9 codes, separated by commas, for the most important
complications/procedures)
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Item 31.
ABNORMAL CONDITIONS AND CLINICAL PROCEDURES RELATING TO THE NEWBORN
(Report codes on reverse.) |
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Do not
enter any identification by patient name or number on this worksheet. Discard after use. Do not
retain the worksheet in the medical records or submit with the “Certificates
of Live Birth.” |
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VS-10A MEDICAL DATA SUPPLEMENTAL WORKSHEET
(REVERSE)
CERTIFICATE OF LIVE BIRTH, MEDICAL
DATA SUPPLEMENTAL WORK SHEET (Continued)
(Circle up to ten codes for the most important conditions/procedures.)
Item
31. ABNORMAL CONDITIONS AND CLINICAL PROCEDURES RELATING TO THE NEWBORN
(Circle up to ten codes for the most important conditions/procedures.)
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CENTRAL NERVOUS SYSTEM (CNS) |
RESPIRATORY SYSTEM |
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