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[](https://www.cdc.gov/nchs/data/dvs/GuidetoCompleteFacilityWks.pdf)
This guide was developed to assist in completing the facility worksheets for the Certificate of Live Birth and Report of Fetal Death (2003 revision).
It provides item numbers, definitions, instructions, best sources, and expected keywords and abbreviations.
For additional training, see Applying Best Practices for Reporting Medical and Health Information on Birth Certificates.
How to Use This Guide
This guide provides definitions, instructions, sources, and keywords and abbreviations for each item on the facility worksheets of the Certificate of Live Birth and the Report of Fetal Death.
Items are shown as follows:
#. Item name (number refers to the order in which the question appears on the U.S. Standard Certificate of Live Birth)
Category: (All items are in a larger category)
BC # (Number on the U.S. Standard Certificate of Live Birth)
FDFWS # (Number on the facility worksheet for the Report of Fetal Death)
FDR # (Number on the Report of Fetal Death)
| Definitions | Defines the item | |
|---|---|---|
| Instructions | If needed, provides specific instructions for completing each item | |
| Sources | Identifies the sources in the medical records where information for each item can be found. The specific records available will differ somewhat from facility to facility. The source listed first is considered the best or preferred source. Please use this source whenever possible. All subsequent sources are listed in the order of preference. The precise location within the records where an item can be found is further identified by under and or . | Example: To determine whether gestational diabetes is recorded as a “Risk factor in this pregnancy” (item #14) in the records: The first or best source is the prenatal care record. Within the prenatal care record, information on diabetes may be found under : Medical history Previous obstetric (OB) history Problem list or initial risk assessment Historical risk summary Complications of previous pregnancies Factors in this pregnancy |
| Keywords and Abbreviations | Identifies alternative terms (usually synonymous) and common abbreviations and acronyms for items. The keywords and abbreviations given in this guide are not intended to be exhaustive; facilities and practitioners will likely add to the list. | Example: Keywords and abbreviations for prepregnancy diabetes are: DM – Diabetes mellitus Type 1 diabetes IDDM – Insulin dependent diabetes mellitus Type 2 diabetes Noninsulin dependent diabetes mellitus Class B DM Class C DM Class D DM Class F DM Class R DM Class H DM |
| Medications commonly used for items. | Example: “Clomid” for “Assisted reproduction treatment.” | |
| Look for is used to indicate terms that may be associated with, but are not synonymous with, an item. Terms listed under look for may indicate that an item should be reported for the pregnancy, but additional information will be needed before it can be determined whether the item should be reported. | Example: “Trial of labor” for “cesarean delivery.” |
Who is the mother?
Mother: The woman who gave birth to, or delivered the infant.
All birth certificate information reported for the mother should be for the woman who delivered the infant.
In cases of surrogacy or gestational carrier, the information reported should be for the surrogate or the gestational carrier, that is, the woman who delivered the infant.
What to do with missing information
Where information for an item cannot be located, please check “unknown” or write “unknown” (if using the paper copy of the worksheet).
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