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Congenital Syphilis Surveillance Form v3.0 (July 2018) CONFIDENTIAL Page 1 of 2CIDR Event ID: Section A: Patient (Child) Information 1. Patients Hospital No.:2. Hospital Name:3. Forename: 4. Surname: 8.

How to fill out congenital syphilis surveillance form

How to fill out congenital syphilis surveillance form

1. To fill out the congenital syphilis surveillance form, follow these steps: 1. Begin by entering the patient's personal information, such as full name, date of birth, and contact details.
2. Specify the date of the mother's first prenatal care visit and the gestational age at that time.
3. Indicate whether the mother had a history of syphilis infection during this or any other pregnancy.
4. Provide information about the mother's serologic test results, including the date of the first positive test and the titer value.
5. Record all dates and results of syphilis tests performed on the mother during pregnancy.
6. Document the start and end dates of maternal treatment for syphilis, along with the regimen used.
7. Note any complications during pregnancy or labor related to syphilis infection.
8. Enter the infant's information, including date of birth, birthweight, and Apgar score.
9. Specify if the infant had any clinical signs of congenital syphilis, such as rash, hepatosplenomegaly, or jaundice.
10. Provide details about the infant's syphilis testing, including the date of the first positive test and the titer value.
11. Record the dates and results of syphilis tests performed on the infant after birth.
12. Document the start and end dates of infant treatment for syphilis, along with the regimen used.
13. Finally, review all the information entered on the form for accuracy and completeness before submitting it.

Who needs congenital syphilis surveillance form?

1. The congenital syphilis surveillance form is required to be filled out by healthcare professionals who are involved in the diagnosis, treatment, and monitoring of pregnant women and infants at risk of or affected by congenital syphilis.
2. This includes obstetricians, gynecologists, pediatricians, infectious disease specialists, and other healthcare providers who come into contact with such cases.
3. Health departments and institutions responsible for public health monitoring and reporting may also use this form for surveillance purposes.

For pdfFiller’s FAQs

What is congenital syphilis surveillance form?

Congenital syphilis surveillance form is a document used to track and monitor cases of syphilis in newborn babies.

Who is required to file congenital syphilis surveillance form?

Healthcare providers, hospitals, and laboratories are required to file congenital syphilis surveillance form.

How to fill out congenital syphilis surveillance form?

The form can be filled out by providing information about the newborn, mother, syphilis test results, and treatment received.

What is the purpose of congenital syphilis surveillance form?

The purpose of the form is to ensure early detection and treatment of syphilis in newborns to prevent serious health complications.

What information must be reported on congenital syphilis surveillance form?

Information such as the baby's name, date of birth, mother's syphilis status, test results, and treatment information must be reported.

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