15. Infections present and/or treated during this pregnancy
Category: Prenatal Care and Pregnancy History
BC # 42
| 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. |
| Definitions | A positive test or culture for Neisseria gonorrhoeae. |
|---|---|
| Instructions | |
| Sources | 1st Prenatal record under –
2nd Labor and delivery nursing admission triage form under – Comments 3rd Admission history and physical (H&P) under –
4th Delivery record under –
|
| Keywords and Abbreviations |
GC Gonorrheal Gonoccocal Treatment or Rx for Gonocchea NAAT–Nucleic amplification tests |
| Definitions | A positive test for Treponema pallidum. |
|---|---|
| Instructions | |
| Sources | 1st Prenatal record under –
2nd Labor and delivery nursing admission triage form under – Comments 3rd Admission history and physical (H&P) under –
4th Delivery record under –
|
| 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 |
| Definitions | A positive test for Chlamydia trachomatis. |
|---|---|
| Instructions | |
| Sources | 1st Prenatal record under –
2nd Labor and delivery nursing admission triage form under – Comments 3rd Admission history and physical (H&P) under –
4th Delivery record under –
|
| Keywords and Abbreviations |
Treatment or Rx for chlamydia |
| Definitions | A positive test for the hepatitis B |
|---|---|
| Instructions | |
| Sources | 1st Prenatal record under –
2nd Labor and delivery nursing admission triage form under – Comments 3rd Admission history and physical (H&P) under –
4th Delivery record under –
|
| Keywords and Abbreviations |
Hep B HBV Treatment or Rx for hepatitis B |
| Definitions | A positive test for the hepatitis C virus |
|---|---|
| Instructions | |
| Sources | 1st Prenatal record under –
2nd Labor and delivery nursing admission triage form under – Comments 3rd Admission history and physical (H&P) under –
4th Delivery record under –
|
| Keywords and Abbreviations |
Hep C HCV Treatment or Rx for hepatitis C |