PAMR # XXXX-XX

OHIO PREGNANCY ASSOCIATED MORTALITY REVIEW CASE SUMMARY

CASE #

CASE RECORDS:

Records Available:

Record Type / Available / Deficiencies or Discrepancies
Yes / No
Prenatal
Labor and Delivery
Postpartum Visit
Terminal Event
Coroner’s Report
Autopsy Report
Toxicology
EMS/Transport
Other Hospitalizations
Social Services
Other –

Records Unable to Be Accessed:

Documentation Discrepancies:

Lapses in Care:

Other:

INFORMATION FROM DEATH CERTIFICATE:

Demographics:

PAMR Case:
Age: / Race/Ethnicity:
Place of Birth: / Education:
Marriage
Status: / Single/Never Married / Single Living with Partner
Married / Divorced
Separated / Widowed
Occupation:
Insurance: / None / Medicaid
Private / Not Documented
Unknown / Other Government

Causes of Death (Death Certificate):

Immediate:

Underlying:

Manner of Death (Death Certificate):

Pregnancy Box Checked:

At time of death
Within 1-42 days of death
Within 43 days to 1 year

Autopsy:

Autopsy findings available to complete cause of death:

Reported to Medical Examiner:

COMMUNITY INFORMATION:

Community:

Perinatal Region:

Delivering Facility:

Neonatal Level:

Trauma Designation Level:

Number of Hospital Beds:

Facility at Death:

Neonatal Level:

Trauma Designation Level:

Number of Hospital Beds:

Other Facility:

Neonatal Level:

Trauma Designation Level:

Number of Hospital Beds:

Case Summary Synopsis:

She was a _____ year old, _____ (race), gravida ___para ___ woman. Medical history was significant for ___. Entry into prenatal care was at ___ weeks with _#__ visits at a ____ with a ___. Prenatal history was significant for ___. Referrals during prenatal period were to ___. History prior to delivery included______. At _____ weeks, she ______. Delivery was by a ____, method was ____, with ____ anesthesia in a hospital that had a Level ____nursery. Obstetric complications included ____. Fetus/ infant was ___ weeks gestation and weighed ___ pound/ounces and complications were ____. The post-partum period was complicated by ______. She developed _____ at ____weeks’ gestation or _____post-partum. She died with cause of death ____, ___ days /months, before, during or after delivery. Autopsy was done by a ___. Significant findings included ____.

1. MEDICAL HISTORY

General History:

Immunization History:

Sexual History:

Obstetrical History:

Contraceptive:

Breast feeding in last 24 months:

Births over 9 pounds:

Menstrual Cycle:

Previous Pregnancy Problems:

Reason for initial appointment:

Current Medications:

Prior Hospitalization:

2. BODY HABITUS

HEIGHT / WEIGHT / BODY MASS INDEX
ANTE-PARTUM
INTRA-PARTUM
POST-PARTUM
AUTOPSY
OTHER
PRE-PREGNANCY / INTRA-PARTUM / POST-PARTUM / AUTOPSY
RISK ASSESSMENT
TOBACCO
ALCOHOL
OTHER SA
HOUSING
MENTAL HEALTH
FAMILY VIOLENCE
POVERTY
COMMUNICATION/BELIEF
TRANSPORTATION
REFERRALS
EDUCATION
ENVIRONMENTAL
FAMILY PLANNING
4. PAYOR SOURCE
PRE-PREGNANCY / INTRA-PARTUM / POST-PARTUM / AUTOPSY
PAYOR SOURCE

5. Prenatal Care RecordMark one: Complete Partial

Provider:

Prenatal Care:

First Visit:

Last Visit:

Location:

Referred for Specialist Care/Type of Specialist/Date and Reason for Referral:

☐Yes☐No☐Not Documented

Specialty / Patient Seen / Findings/Recommendations
Yes / No

Number of Prenatal Visits:

Pregnancy Planned? Planned/Unplanned/No Source Data

Last Menstrual Period:

EDD by Dates:

EDD by Sonogram:

Gravida: Para:

Maternal or Infant Genetic Problems:

Previous Pregnancy History: (Do NOT include pregnancy closest to mother’s death.)

Date / Pregnancy Outcome / Birth Weight / Gestational Age / Maternal Complications / Current Status

Laboratory Screening Tests:

Initial:

☐None☐Not Documented

Lab Test / Date / Results / If Abnormal, Action/Repeat Results
Hgb/Hct
Platelets
Blood Type
Rh Screen
Rubella
HbsAG
HIV
Syphilis
Gonorrhea
Chlamydia
PAP Smear
Urinalysis

Other and Repeated Labs:

☐None☐Not Documented

Lab Test / Date / Results / If Abnormal, Action/Repeat Results
MSAFP
GCT
GTT
GBBS
Drug Screen
Urine C & S
TB Test
Wet Mount & KOH
HSV Culture
Other:
Other:

Comments:

Procedures:

Medications:

☐Yes☐No☐Not Documented

Date / Dose/Frequency / Reason Prescribed

Information on prenatal visits: (from Prenatal Care Visits Attachment)

DATE / GA WEEKS / WT / BP / FHT / FUNDAL HEIGHT / URINE G/P / COMMENTS/PROCEDURES

*Note: If this woman was hospitalized prior to the hospital visit which included Labor and Delivery, please cut and paste that hospitalization here.

3. Labor and Delivery Record

Location:

Level of Hospital:

Date/Time of Admission:

Admitting Diagnosis:

Vital Signs on Admission:

Onset of Labor:

Status upon Arrival:

Membranes:

Primary Provider for Labor and Delivery:

Other Providers:

Duration in Labor:

Medical Problems:

Obstetrical Problems:

Labs/Procedures:

Date/time / Lab Test / Results

Presentation:

Type of Delivery:

Type of Induction:

Reason for C-Section:

Date/Time of Delivery:

Anesthesia:

Medications: (Include date/time started and amount for blood products, magnesium sulfate, and antibiotics)

Status of Baby:

☐ Live Birth☐ Still Birth

Weight:Length:Head:

Infant Apgars:one minute/five minute

Resuscitation Efforts:

Transferred:

Contact with Mother:

Referrals:

Postpartum Vital Signs:

☐Not Documented

Vital Signs: / Temperature / Pulse / Respirations / Blood Pressure
1 Hour
2 Hour
3 Hour
4 Hour
Day 1
Day 2
Day 3
Discharge

Postpartum Complications:

Significant Health Conditions:

Placenta Report:

Discharged:

Discharge Vital Signs:

Discharge Follow-up:or

Summarization of Events Prior to Demise:

4. POSTPARTUM (AFTER DISCHARGE)

Postpartum Care:(from Attachment)

Date/Time:

Place:

Reason for Visit:

Condition:

Labs/Procedures:

Follow-up:

Outpatient Visits: (from Attachment)(Duplicate this section as needed)

Date/Time:

Place:

Reason for Visit:

Condition:

Vital Signs/Weight:

Labs/Procedures:

Follow-up:

Comments:

  • Please note reasons for lapses in care, i.e. no follow-up, missed appointments, unable to locate other records, etc.

Hospitalization #____

(May have multiple entries. Insert the data for each hospitalization into this document in chronological order, and designate as #1, #2, #3 etc.)

Level of Hospital:

Date/Time of Admission:

Admitting Diagnosis/Condition:

Events

Final Disposition:

Physical Exam on Admission:

Pregnancy Status:

Labs:

Date/time

Tests:

Medications:

Date / Dose/Frequency / Reason Prescribed

Providers:

Consultants:

Discharge Planningor

Events Surrounding Demise:

Transport

Date/Time:

Medical Reason:

Maternal Condition:

Fetal/Neonatal Condition:

Transport Manager:

Vehicle:

Timing:

Level of Referring and Receiving Hospitals:

Procedures before Transport:

Procedures in Transport:

Transport Vital Signs:

Terminal Event

Date/Time of Death:

Age:

Place of Death:

Weight:Height:

Resuscitation:

Law Enforcement:

Certifier of Death:

Medical Provider 24 hours before Death:

Place of Transport:

Investigative Information:

Autopsy: Done by:

Medical Examiner Case:

Autopsy Findings:

Toxicology:

Cause of Death:

Medical record:

Autopsy record:

Manner of Death:

Bereavement/Grief Support

L & D Bereavement:

Hospital Documentation of Grief Support:

Transport Documentation of Grief Support:

Terminal Event Documentation of Grief Support:

  1. General Incident Information
  1. Intent of Injury
  2. Unintentional
  3. Intentional
  4. Site of Injury (Wherewoman was discovered—may or may not be the site of her death)
  5. Public property
  6. Private property
  7. Time of incident
  8. Location of incident
  9. House/Apartment
  10. Street/Road
  11. Motor vehicle
  12. Commercial establishment
  13. Public building
  14. Workplace
  15. Parking lot / Garage
  16. Hospital
  17. Hotel/Motel
  18. Park/Playground
  19. Natural area
  20. Other
  21. Unknown
  22. Witnesses:Was the injury/death witnessed or was she discovered at a known or unknown time later?
  23. If witnessed, how many individuals?
  24. EMS information
  25. Was EMS activated (911 called)?
  26. If so, when?
  27. Time of dispatch?
  28. Bystander CPR initiated?
  29. Time of arrival?
  30. Response time appropriate?
  31. Was an AED used?
  32. Influence of drugs/alcohol?
  33. Other fatalities of incident?
  34. If so, number of individuals?
  35. Was law enforcement involved?
  1. Mechanism of Injury
  1. Poisoning (including drug overdoses)
  2. Presence of multiple drugs in decedent’s system?
  3. Type of substance
  4. Prescription
  5. Antidepressant
  6. Blood pressure meds
  7. Pain killer
  8. Opiate
  9. Non-opiate
  10. Methadone
  11. Cardiac medication
  12. Other
  13. OTC
  14. Diet pills
  15. Stimulants
  16. Cough medicine
  17. Pain medication
  18. Cosmetics/personal care products
  19. Other
  20. Cleaning substances
  21. Specify type
  22. Alcohol
  23. Blood alcohol concentration?
  24. Street drugs
  25. Heroin
  26. Cocaine
  27. Methamphetamine
  28. Hallucinogenic agents
  29. Designer drugs (e.g. ecstasy, GHB)
  30. Carbon monoxide
  31. If so, functioning detector present?
  32. Other fume/gas/vapor
  33. Other
  34. Injury due to:
  35. Accidental overdose
  36. Medical treatment mishap
  37. Adverse effect, but not overdose
  38. Acute intoxication
  39. Other
  40. Unknown
  41. Additional comments about incident?
  1. Motor Vehicle Traffic and Other Transport Crashes
  2. Single vs. multi-vehicle involvement
  3. If multiple, total number of vehicles involved in incident
  4. Time of day
  5. Dawn
  6. Daylight
  7. Dusk
  8. Dark
  9. Number of occupants in decedent’s vehicle
  10. Type(s) of vehicle
  11. Motorcycle
  12. Car
  13. SUV
  14. Truck
  15. Semi
  16. Buggy
  17. All-Terrain Vehicle (ATV)
  18. Pedestrian
  19. Bicycle
  20. Other
  21. Unknown
  22. Location of crash
  23. Street
  24. City
  25. Residential
  26. Rural road
  27. Highway
  28. Intersection
  29. Shoulder
  30. Sidewalk
  31. Driveway
  32. Parking area
  33. Train tracks
  34. Off road
  35. Other
  36. Unknown
  37. Position of decedent
  38. Driver
  39. Passenger
  40. Front seat
  41. Back seat
  42. Truck bed
  43. Other
  44. Unknown
  45. On bicycle
  46. Pedestrian
  47. Driving conditions
  48. Normal
  49. Loose gravel
  50. Muddy
  51. Ice/snow
  52. Fog
  53. Wet
  54. Construction zone
  55. Other
  56. Unknown
  57. Weather conditions
  58. Safety equipment / Protective measures
  59. Presence of seat belt?
  60. Lap
  61. Shoulder
  62. Used correctly?
  63. Ejected?
  64. Airbag
  65. Presence of helmet?
  66. Other
  67. Causes of accident (Select all that apply)
  68. Speeding over limit
  69. Unsafe speed for conditions
  70. Recklessness
  71. Ran stop sign or red light
  72. Distracted driving
  73. Inexperience driving
  74. Mechanical failure
  75. Poor tires
  76. Poor weather conditions
  77. Poor visibility
  78. Drugs or alcohol use
  79. Fatigue/sleeping
  80. Medical event
  81. If medical event, specify type
  82. Flipover
  83. Car changing lanes
  84. Road hazard
  85. Animal in road
  86. Cell phone use while driving
  87. Other driver error
  88. If other, specify type
  89. Additional comments about incident?
  1. Falls
  2. Height of fall (feet and inches)
  3. Origin of fall
  4. Bridge
  5. Overpass
  6. Balcony
  7. Roof
  8. Ladder
  9. Stairs
  10. Natural elevation
  11. Vehicle
  12. Same level
  13. Other
  14. Unknown
  15. Surface of landing after fall
  16. Cement/concrete
  17. Grass
  18. Gravel
  19. Water
  20. Floor (wood/carpeted)
  21. Other
  22. Unknown
  23. Additional comments about incident?
  1. Crush
  2. Object causing crush
  3. Additional comments about incident?
  1. Asphyxia
  2. Type
  3. Suffocation
  4. Strangulation
  5. Object causing strangulation
  6. Manual (e.g. hand, arm, knee, etc.)
  7. Ligature (e.g. clothing, cord, rope, etc.)
  8. Choking
  9. Object causing chocking
  10. Food
  11. Other
  12. Unknown
  13. Heimlich maneuver attempted?
  14. Other
  15. Unknown
  16. Asphyxia result of autoerotic event?
  17. Additional comments about incident?
  1. Drowning
  2. Location of drowning
  3. Bathtub
  4. Pool / hot tub
  5. Type of pool
  6. Above ground
  7. In-ground
  8. Hot tub
  9. Public or private ownership
  10. Open water
  11. Type
  12. Still body of water (e.g. lake, pond)
  13. River
  14. Ocean
  15. Other
  16. Unknown
  17. Contributing environmental conditions
  18. Weather
  19. Temperature
  20. Current
  21. Riptide
  22. Rough waves
  23. Other
  24. Unknown
  25. Decedent’s activity prior to incident
  26. Recreational (e.g. boating, fishing, tubing, etc.)
  27. If boating, type of boat?
  28. Swimming
  29. Bathing
  30. Other
  31. Unknown
  32. Ability to swim?
  33. Use of flotation device?
  34. Influence of chronic medical conditions?
  35. Additional comments about incident?
  1. Fire/Burns
  2. Fire started by decedent?
  3. Type of ignition or heat source
  4. Type of building on fire
  5. Single home
  6. Duplex
  7. Apartment
  8. Mobile home
  9. Other
  10. Unknown
  11. Details about building
  12. Barriers preventing safe exit
  13. Presence of functioning sprinkler system
  14. Presence of functioning smoke detectors
  15. Presence of functioning fire alarm
  16. Mechanism
  17. Additional comments about incident
  1. Weapons, including Body Parts
  2. Type Weapon
  3. Firearm
  4. Who handled the weapon?
  5. Self
  6. Another individual
  7. Unknown
  8. Type of firearm
  9. Handgun
  10. Rifle/shotgun
  11. Other
  12. Unknown
  13. Location/Storage of firearm?
  14. Not stored
  15. Locked cabinet/closet
  16. Unlocked cabinet/closet
  17. Glove compartment
  18. Under mattress/pillow
  19. Other
  20. Unknown
  21. Proper storage of firearm?
  1. Sharp/Blunt Instrument
  2. Type of instrument
  3. Knife
  4. Blade
  5. Hammer
  6. Pipe
  7. Bat
  8. Rock
  9. Household item
  10. Other
  11. Unknown
  12. Person’s body part
  13. Body part’s action
  14. Beat, kick, or punch
  15. Drop
  16. Push
  17. Bite
  18. Throw
  19. Other
  20. Unknown
  21. Other
  22. Specify
  23. Unknown
  1. Additional comments about incident?
  1. If Intentional Injury, Detailed Information
  1. Suicide & Self Harm
  2. Did decedent leave suicide note?
  3. History of suicide attempt(s)
  4. If yes, how many?
  5. Presence of mental health circumstances
  6. Alcohol problem
  7. Depressed mood
  8. History of mental health problem(s)
  9. Current diagnosed mental problem (s)
  10. Other substance abuse
  11. Receiving mental health treatment
  12. Presence of life problems or stressors
  13. Health
  14. Job
  15. Recent crisis (timeframe?)
  16. Financial
  17. Legal
  18. Criminal
  19. Non-criminal
  20. School
  21. Alcohol or substance use
  22. Other
  23. Presence of Relationship problems/stressors
  24. Intimate partner problem / violence
  25. Other relationship problem (non-intimate)
  26. Suicide of family member
  27. Years prior to decedent’s death?
  28. Other type of death of family member
  29. Years prior to decedent’s death?
  30. Presence of drugs in system / Toxicology
  31. Prescription
  32. Amphetamines
  33. Antidepressant
  34. Pain killer
  35. Opiate
  36. Non-opiate
  37. Methadone
  38. Alcohol
  39. Blood alcohol concentration?
  40. Street drugs
  41. Heroin
  42. Cocaine
  43. Methamphetamine
  44. Hallucinogenic agents
  45. Designer drugs (e.g. ecstasy, GHB)
  1. Homicide & Assault
  2. Number of victims
  3. Single homicide
  4. Multiple homicide
  5. If so, how many other victims?
  6. Murder – suicide
  7. Perpetrator known?
  8. Gender of perpetrator
  9. Age of perpetrator
  10. If so, relationship to decedent?
  11. Spouse
  12. Ex-spouse
  13. Girlfriend/Boyfriend
  14. Ex-girlfriend/ex-boyfriend
  15. Child
  16. Parent (including step-parent)
  17. Sibling
  18. Friend
  19. Roommate
  20. Acquaintance
  21. Other
  22. Unknown
  23. Confession given?
  24. Crime-related circumstances related to homicide?
  25. Drug involvement
  26. Triggered by another crime
  27. Brawl
  28. Bystander
  29. Hate crime
  30. Mentally ill suspect
  31. Other
  32. Unknown
  33. Personal conflicts / arguments related to homicide
  34. Argument about money / property
  35. IPV
  36. Partner’s history with decedent
  37. Years together?
  38. Children?
  39. If so, how many?
  40. Child custody proceedings
  41. Separation/divorce proceedings
  42. Reports to law enforcement
  43. Prior incidents of decedent
  44. Prior incidents of suspect/perpetrator
  45. Restraint orders
  46. If so, number of restraint orders?
  47. History of partner arrests
  48. Solicitation charges for decedent
  49. Jealousy (Love triangle)
  50. Substance or alcohol problem
  51. Decedent
  52. Perpetrator/suspect
  53. Other
  54. Presence of drugs in system / Toxicology
  55. Prescription
  56. Amphetamines
  57. Antidepressant
  58. Pain killer
  59. Opiate
  60. Non-opiate
  61. Methadone
  62. Alcohol
  63. Blood alcohol concentration?
  64. Street drugs
  65. Heroin
  66. Cocaine
  67. Methamphetamine
  68. Hallucinogenic agents
  69. Designer drugs (e.g. ecstasy, GHB)
  70. Other
  71. Legal Outcomes
  72. Criminal charges
  73. No charges filed
  74. Charges filed, specify
  75. Charges dismissed
  76. Guilty verdict
  77. Not guilty verdict
  78. Unknown

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