Not Screened for Critical Congenital Heart Disease (CCHD) by Pulse Oximetry
INSTRUCTIONS
When a baby is not screened for critical congenital heart disease by pulse oximetry, please record Not Screened on the
newborn blood card and submit this completed form to the Wisconsin State Laboratory of Hygiene (WSLH). If there is no blood
card because of blood screening refusal please submit this form only.
This form may be enclosed with blood cards submitted to the WSLH or mailed separately to the following address:
Newborn Screening Laboratory
Wisconsin State Laboratory of Hygiene
465 Henry Mall
Madison, WI 53706
Completion of this form should NEVER delay submission of blood cards.
1. DEMOGRAPHIC INFORMATION
Mother’s First Name
Baby’s First Name
Baby’s DOB (mm/dd/yyyy)
/
/
Place of Birth
Newborn blood screening card number
Mother’s Last Name
Baby’s Last Name
Gender
Girl
Boy
Not Applicable (blood screening refused)
2. REASON PULSE OXIMETRY WAS NOT PERFORMED
Significant congenital heart disease confirmed by postnatal echocardiography
Significant congenital heart disease excluded by postnatal echocardiography
Death before pulse oximetry screening could be performed
Parent(s) refused pulse oximetry screening
Baby transferred before screening was appropriate, receiving institution
Other
3. ECHO RESULTS/CARDIOVASCULAR DIAGNOSTIC INFORMATION
Date of the echo (mm/dd/yyyy)
/
/
Location of echo
Normal
Cardiac findings not requiring treatment (PFO, small PDA, small VSD, etc.)
Persistent Fetal Circulation
Clinically Significant Patent Ductus Arteriosus
Significant Congenital Heart Disease
Diagnosis #1
Diagnosis #2
Diagnosis #3
Other
No echocardiogram was performed
If present, how was congenital heart disease first suspected? (Check all that apply)
Prenatal diagnosis
Symptoms
Abnormal physical examination
Screening echocardiogram because of genetic syndrome or congenital anomaly
Echocardiography performed for other reasons
Other
4. COMMENTS
08/2014
For questions call SHINE (UW on call operator) at 608-262-2122
www.wisconsinshine.org