Severe Maternal Morbidity Form

Patient Record ID Number/MRN

Please select hospital name

Hospital Level (maternal and infant healthcare services)

Email address of person completing form.

Reason(s) patient identified as a Severe Maternal Morbidity (SMM) case

Other Complications

Was the patient's baby(ies) viable?

Note:
A viable delivery/baby is one in which developed and survived outside of the uterus.

How was the patient/case identified for SMM Review?

Other (Write in)

Abstractor Name

Date of Abstraction

Patient Admission Date

Patient Discharge Date

Which ICD-10 or Procedures Codes were used to verify patient's SMM condition?

NOTE: To view all SMM ICD-10 and Procedure Codes, visit the following webpage: https://www.cdc.gov/maternal-infant-health/php/severe-maternal-morbidity/icd.html

Was patient transported from another facility?

Which facility was the patient transported from?

Was patient transferred to another facility?

Which facility was patient transferred to?

Date when SMM was identified

Timing of SMM-Related Care (Select all that apply)

What is the age of the patient?

Is the patient Hispanic and/or of Hispanic Origin?

Patient's Race (Select all that apply)

Patient's Current BMI Range

What is the patient's current payor source/insurance carrier?

Patient's Gravida

Patient's Para

Number of Preterm Deliveries

Number of Living Children

Number of previous fetal deaths

Number of previous infant deaths

Gestational Age at Time of SMM Onset

Location of Delivery (Select all that apply)

Other Delivery Location

Level of Maternal Care Facility (Location of Delivery)

Delivery Type

If patient had C-Section, select the reason(s)

Other Reason for C-Section

When did patient begin prenatal care?

Are there any known and/or documented gaps in prenatal care?

Note:
Gaps in prenatal care includes visits that were not consistent to provider guidelines, missed screenings/interventions, skipped/missed scheduled visits, follow-ups, etc.

Is there documented evidence that patient was enrolled into any home visiting program(s), coordinated care initiative(s)/CCO, comprehensive patient care service(s), etc.?

Documented Completed Peripartum Consultation(s) Prior to SMM

Other Consultations (Peripartum)

Where did the patient receive prenatal care?

Patient's Past Medical Conditions History (if known)

Other Disorder or Health Condition

Has patient ever been diagnosed with a mental health condition (according to records)?

Type(s) of Documented Mental Health Condition(s)

Note:
Mental health conditions include, but are not limited to, post partum depression, anxiety, bipolar disorder, eating disorder, post-traumatic stress disorder, schizophrenia, etc.

Does patient have any of the following social determinants of health [social factors] documented in records?

Other Social Determinants of Health Issues

Use this section to provide a brief chart summary of SMM events.

Example Below:
20 yo G1P0 with complaints of decreased fetal movement in clinic and was sent to hospital for evaluation at 39 2/7. NST reactive, and BPP 4/8 for no fetal tone or movement. MFM recommended IOL. Initial exam 1/60/-3. Cervical balloon placed. Upon removal four hours later, SVE 4/80/-3. Pitocin started. Epidural placed. Four hours later, SVE 6/80/-2, AROM clear fluid. Another four hours later, SVE unchanged and IUPC placed. Five hours later, provider noted Cat 2 tracing, and SVE remained unchanged, despite adequate MVUs and regular contractions. Patient counseled and decision made to proceed with a cesarean birth due to arrest of labor. Uterine atony noted. Methergine, miso, TXA, and Bakri balloon. QBL 1823ml. Massive transfusion protocol initiated. Patient received 4 U PRBCs. Patient remained stable following 24 hr observation in ICU, and transferred to postpartum unit. Infant weight 3560g. Apgars 8/9.