Form Dch 1398 PDF Details

At the intersection of public health and patient care management lies the Perinatal Hepatitis B Intake Form, known formally as the DCH 1398 form. This critical document serves a dual purpose: it is both a reporting tool for healthcare providers and a means to ensure that pregnant women who are carriers of Hepatitis B receive the appropriate follow-up care. The form meticulously collects data ranging from basic demographic information, such as the woman's name, date of birth, and contact details, to more detailed medical history, including Hepatitis B surface antigen (HBsAg) testing results and any need for an interpreter due to language barriers. Furthermore, it delves into the woman's laboratory reports, documenting the presence or absence of various Hepatitis B markers and the viral load, which are crucial for assessing the disease's progression and managing it effectively. The form also captures information regarding the woman's prenatal care provider, the planned hospital for delivery, and any household or sexual contacts that may also be at risk, emphasizing the comprehensive approach towards managing Hepatitis B in a perinatal context. Through its exhaustive data collection, the DCH 1398 form plays an instrumental role in monitoring the spread of Hepatitis B, guiding treatment protocols, and ultimately safeguarding both maternal and neonatal health.

QuestionAnswer
Form NameForm Dch 1398
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other names_PerinatalHepat itisBIntakeForm 040308_231888_7 hepatitis b vaccine intake form

Form Preview Example

Perinatal Hepatitis B Intake Form

Fax to 517/335-9855 or call 517/335-8122 or 800/964-4487 or in southeast Michigan

Fax to 313/456-4427 or call 313/456-4432

Woman’s name ________________________________ Date of birth ____________ Social Security # ______________

Address _________________________________________________ City _____________________ Zip ___________

County _______________ Telephone # _______________ Emergency contact name & # _________________________

Race: Asian/PI

Black White

Amer Indian Alaskan Native Other ____________ Unknown

Ethnicity:

Hispanic

Non-Hispanic

Unknown

Grav ____ Para ____ Country of Birth _________________ Maternal Grandmother’s Country of Birth ______________

Does the woman need an interpreter Y N If yes, what language ___________________

Woman’s Laboratory Reports:

 

 

 

(P = Positive/Reactive; N = Negative/non-reactive; NT = Not tested; U = Unknown)

 

HBsAg _ / _ / _

 

 

P

N

 

NT U

Repeat HBsAg

_ / _

 

/ _

 

P

N NT U

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Date HBsAg reported

 

_

/ _

 

/ _

 

How reported:

Lab–Electronic/Paper

OB

 

 

Hospital

Other ______________

HBeAg

_ / _

 

/

_

 

 

P

N

NT

U

HBeAb

_ / _

/

_

 

P

N

NT

U

Anti-HBc IgM

_ / _

 

/

_

 

 

P

N

NT

U

Anti-HBc

 

_

/ _

/

_

 

P

N

NT

U

HBV DNA

 

_ / _

 

/

_

 

 

P

N

NT

U

HBV Viral Load __________

 

 

 

Other maternal infections/conditions (HCV, HIV, Other STIs, etc) _________________________________________

LHD refer for care/evaluation? Y N U

Hep B treatment during this pregnancy?

Y

N U

If yes, treatment brand/dose __________________

Treatment start date _ / _ / _

 

 

 

 

 

 

 

 

Physician providing treatment _______________________________ Telephone # _________________

Prenatal Care Provider (PCP) Information:

 

 

 

PCP/facility name ________________________________________________ EDC date _

/ _ /

_

 

 

 

 

 

 

 

 

 

Address _____________________________________________ City _________________________ Zip ___________

Telephone # ____________________ Hospital to deliver at _________________________________________________

Reporting information sent to PCP office? Y N Date _ / _ / __

Household/Sexual Contact Information:

First/Last Name

 

 

 

 

 

 

 

 

 

 

HBsAg, anti-HBs

Test

DOB

HBIG

Hep B #1

Hep B #2

Hep B #3

and/or anti-HBc

(relationship)

Date

 

 

 

 

 

 

 

 

 

 

results

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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Household/sexual contact provider name _______________________________________________________________

Address ___________________________ City ___________________ Zip __________ Telephone # ______________

CD Nurse _________________________________________ Telephone # ___________________________________

DCH-1398 AUTHORITY: PA 368 of 1978, as amended

Rev 04/03/08