The Maryland Confidential Morbidity Report is a critical tool utilized by healthcare providers to report specific diseases and conditions to local health departments. This form ensures that vital health information is communicated efficiently, helping to track and manage public health concerns. Understanding the importance of accurate reporting is essential, and healthcare professionals are encouraged to fill out this form diligently by clicking the button below.
The Maryland Confidential Morbidity Report form, designated as DHMH 1140, serves as a vital tool for physicians and other healthcare providers to report specific health conditions and diseases to local health departments. This form is not intended for use by laboratories, which have their own reporting requirements. It collects essential patient information, including demographics such as name, date of birth, sex, and ethnicity, which helps in understanding the population affected by various health issues. The form also captures details about the patient's occupation and potential contact with vulnerable populations, which can influence disease transmission. Furthermore, it requires information on the disease or condition, including its onset date, hospital admission details, and whether the patient has been notified of their condition. Healthcare providers must also indicate if the condition was acquired in Maryland and provide any relevant laboratory test results. The report emphasizes the importance of confidentiality while ensuring that local health authorities can respond effectively to public health concerns. By systematically gathering this information, the form aids in monitoring disease trends and implementing appropriate public health interventions.
Maryland Snap Redetermination Form - Multiple pages reflect different sections of the application to ensure comprehensive data collection.
For individuals preparing for marriage, understanding the importance of a well-prepared Prenuptial Agreement can provide invaluable insights. This document outlines financial arrangements and asset divisions, ensuring clarity and security in the relationship. To explore how to create a solid foundation for your future, consider reviewing the essential Prenuptial Agreement details at essential Prenuptial Agreement insights.
Maryland Crash Reports - Emergency medical services (EMS) involvement is noted, including where injured parties were taken.
MARYLAND CONFIDENTIAL MORBIDITY REPORT (DHMH 1140)
(For use by physicians and other health care providers, but not laboratories. Laboratories should use forms DHMH 1281 & DHMH 4492.)
SEND TO YOUR LOCAL HEALTH DEPARTMENT
STATE DATA BASE NUMBER (Completed by Health Department)
NAME OF PATIENT
– LAST
FIRST
M
DATE OF BIRTH
AGE
SEX
ETHNICITY (Select independently of RACE)
MONTH
DAY
YEAR
HISPANIC or LATINO:
YES
NO
UNKNOWN
F
TELEPHONE NUMBERS
RACE (Select one or more. If multiracial, select all that apply)
Home:
Workplace:
American Indian/Alaskan Native
Asian
Black/African American
Hawaiian/Pacific Islander
White
Unknown
Other (Specify):
ADDRESS
UNIT#
CITY OR TOWN
STATE
ZIP CODE
COUNTY
OCCUPATION OR CONTACT WITH VULNERABLE PERSONS
WORKPLACE, SCHOOL, CHILD CARE FACILITY, ETC.
( Include Name, Address, ZIP Code)
(Check all that apply - include volunteers)
HEALTH CARE WORKER (Include any PATIENT CARE, ELDER CARE, "AIDES," etc.)
DAYCARE (Attendee or Worker)
PARENT of a child in DAYCARE
FOOD SERVICE WORKER
NOT EMPLOYED
OTHER (SPECIFY):
DISEASE OR CONDITION
DATE OF ONSET
ADMITTED
DATE ADMITTED
HOSPITAL
YES
PATIENT HAS BEEN NOTIFIED OF THIS CONDITION
NO
CONDITION ACQUIRED IN MARYLAND
SUSPECTED SOURCE OF INFECTION
DIED
DATE DIED
PREGNANT
NOT APPLICABLE
(IF NO, INTERSTATE , or INTERNATIONAL )
WEEKS PREGNANT __________
DUE DATE ____________________
LABORATORY TESTS - VIRAL HEPATITIS
ADDITIONAL LAB RESULTS
POS
NEG
DATE
HCV Viral Genotyping
____________
DATE _____________
(SPECIMEN - TEST - RESULT - DATE - NAME of LAB)
(Please attach copies of lab reports whenever possible.)
HAV Antibody Total
_____________________
HBV surface Antibody
ALT (SGPT) Level
______________
HAV Antibody IgM
HBV Viral DNA
ALT – Lab Normal Range:
______________ to _____________
HBV surface Antigen
HCV Antibody ELISA
AST (SGOT) Level
HBV e Antigen
HCV ELISA Signal/Cut Off Ratio
AST – Lab Normal Range: ______________ to
HBV core Antibody Total
HCV Antibody RIBA
NAME of LAB:
________________________________________
HBV core Antibody IgM
HCV RNA (eg., by PCR)
PERTINENT CLINICAL INFORMATION + OTHER COMMENTS
HUMAN IMMUNODEFICIENCY VIRUS (HIV) and
–
ADDITIONAL CASE INFORMATION
ACQUIRED IMMUNODEFICIENCY SYNDROME
(AIDS)
CON D IT IO NS
H IV L AB T EST S
D AT E
RESULT
WEIGHT LOSS OR DIARRHEA .............................................
CD4+
T-cells < 200 per microliter or < 14%
SECONDARY INFECTIONS (PCP, TB, etc.).........................
ELISA
PERINATAL EXPOSURE OF NEWBORN .............................
WESTERN BLOT
OTHER CONDITIONS ATTRIBUTED TO HIV INFECTION (SPECIFY):
OTHER (SPECIFY):
PHYSICIAN REQUESTS LOCAL HEALTH DEPARTMENT TO ASSIST WITH: NOTIFICATION TO PATIENT YES NO PARTNER SERVICES YES NO
SEXUALLY TRANSMITTED INFECTION (STI) –
SYPHILIS: PRIMARY
SECONDARY
EARLY LATENT (LESS THAN 1 YR)
CONGENITAL
OTHER STAGE (SPECIFY):
GONORRHEA: CERVICAL
URETHRAL
RECTAL
PHARYNGEAL
OPHTHALMIA NEONATORUM
PID OTHER (SPECIFY):
CHLAMYDIA: CERVICAL
PID
OTHER (SPECIFY):
OTHER STI (Specify):
STI LABORATORY CONFIRMATION AND TREATMENT
Specify STI Lab Test (e.g., RPR Titer, FTA – TPPA, Darkfield, Smear, Culture, NAAT, EIA, VDRL - CSF)
TEST
STI Treatment Given (Specify date – drug – dosage below)
No Treatment Given
DRUG
DOSAGE
TUBERCULOSIS (Suspect or Confirmed) – ADDITIONAL CASE INFORMATION
MAJOR SITE: PULMONARY
EXTRAPULMONARY
ATYPICAL (SPECIFY )
ABNORMAL CHEST X-RAY:
COMMENTS:
REPORTED BY
TELEPHONE NUMBER
DATE OF REPORT
MONTH DAY YEAR
Check here if completed by the Health Department
NOTES: Your local health department may contact you following this initial report to request additional disease-specific information. To print blank report forms or get more information about reporting, go to http://ideha.dhmh.maryland.gov/SitePages/what-to-report.aspx.
DHMH 1140 REVISED JANUARY 26, 2012
Understanding the Maryland Confidential Morbidity Report form is essential for healthcare providers. However, there are several misconceptions that may lead to confusion. Here are eight common misunderstandings:
By addressing these misconceptions, healthcare providers can ensure accurate reporting and contribute to the overall health of the community.
Filling out the Maryland Confidential Morbidity Report form accurately is crucial for effective public health monitoring. However, many individuals make common mistakes that can lead to incomplete or inaccurate submissions. Understanding these errors can help ensure that the form is filled out correctly, which ultimately benefits the health department and the community.
One frequent mistake is neglecting to provide complete patient information. The form requires specific details such as the patient’s full name, date of birth, and contact information. Omitting any of this information can delay the processing of the report and hinder public health responses. Ensure that all fields are filled out thoroughly to avoid this issue.
Another common error involves the selection of race and ethnicity. It is essential to select these categories independently. Failing to do so can lead to misclassification, which impacts data accuracy. Be diligent in checking the appropriate boxes and providing as much detail as possible.
Many people also overlook the importance of specifying the suspected source of infection. This section is critical for tracking disease outbreaks and understanding transmission patterns. If you are unsure, it is better to indicate "unknown" rather than leaving it blank. Providing as much context as possible can aid health officials in their investigations.
Additionally, individuals often forget to check the box regarding whether the patient has been notified of their condition. This information is vital for follow-up care and public health interventions. If the patient has not been informed, it should be noted clearly on the form.
In the section regarding laboratory tests, mistakes frequently occur. Some individuals fail to attach necessary lab reports or provide incomplete test results. This omission can lead to misunderstandings about the patient's condition. Always include copies of relevant lab reports when submitting the form.
Another mistake is not indicating the patient’s occupation or contact with vulnerable populations. This information is critical for assessing potential risks and implementing appropriate public health measures. Be thorough in detailing the patient's work environment and any interactions with at-risk groups.
People sometimes misinterpret the sections related to sexually transmitted infections (STIs). It is important to specify the correct stage of the infection and provide accurate treatment information. Mislabeling or failing to provide this data can hinder effective tracking and treatment efforts.
Lastly, many individuals neglect to review the form before submission. Errors can easily slip through, and a final check can catch mistakes that may have been overlooked. Taking a moment to review the completed form can prevent delays and ensure that all necessary information is accurately reported.
By being aware of these common mistakes, individuals can improve the accuracy of the Maryland Confidential Morbidity Report. This diligence not only aids in individual patient care but also strengthens public health efforts across the state.
The Maryland Confidential Morbidity Report form is intended for use by physicians and other healthcare providers, not laboratories. Laboratories should utilize different forms.
It is crucial to send the completed form to your local health department. They will assign a state database number for tracking purposes.
Accurate patient information is essential. This includes the patient's name, date of birth, age, sex, and ethnicity. Make sure to select ethnicity independently of race.
When reporting the disease or condition, include details such as the date of onset and whether the patient has been notified about their condition.
Include pertinent clinical information and laboratory test results. Providing copies of lab reports can enhance the quality of the report.
After submission, your local health department may reach out for additional information related to the disease. Stay prepared to provide further details if requested.
The Maryland Confidential Morbidity Report (DHMH 1140) plays a crucial role in tracking and managing public health concerns. It is essential for healthcare providers to understand the various forms and documents that often accompany this report. Each of these documents serves a unique purpose in ensuring comprehensive data collection and effective communication with local health departments. Below are five key forms that are frequently used alongside the Maryland Confidential Morbidity Report.
Understanding these forms and their purposes can significantly enhance the reporting process and improve public health outcomes. By ensuring accurate and timely communication, healthcare providers and local health departments can work together effectively to safeguard community health.
The Maryland Confidential Morbidity Report form is similar to the CDC's National Notifiable Diseases Surveillance System (NNDSS) form. Both documents serve the purpose of reporting specific diseases to public health authorities. The NNDSS collects data on various infectious diseases to monitor trends and outbreaks across the country. Like the Maryland form, it requires detailed patient information, including demographics and disease specifics, to ensure accurate tracking and response by health departments.
Another document that resembles the Maryland Confidential Morbidity Report is the State Health Department's Reportable Disease Form. This form is used in various states to report cases of diseases that are mandated by law. It focuses on patient demographics, clinical information, and disease details. Similar to the Maryland form, it helps public health officials identify and control outbreaks by collecting essential data from healthcare providers.
The Infectious Disease Reporting Form used in many hospitals is also comparable. This internal document is designed for healthcare providers to report cases of infectious diseases to their institution's infection control team. Like the Maryland form, it includes patient demographics and clinical details. The goal is to ensure that healthcare facilities can take necessary precautions to prevent the spread of infections within their walls.
The HIV/AIDS Reporting Form is another similar document. This form is specifically for reporting cases of HIV and AIDS to state health departments. It collects critical information about the patient’s demographics, clinical status, and laboratory results. Just like the Maryland form, it aims to facilitate effective public health responses and monitoring of the disease's prevalence.
In addition, the Tuberculosis (TB) Case Report Form shares similarities with the Maryland form. This document is used to report suspected or confirmed cases of TB to local health authorities. It gathers detailed information about the patient, including demographics and clinical data, to assist in tracking and managing TB outbreaks, mirroring the objectives of the Maryland report.
The Vaccine Adverse Event Reporting System (VAERS) form is another related document. While it focuses on reporting adverse events following vaccinations, it shares the same goal of protecting public health. Both forms collect patient demographics and specific clinical information to ensure thorough investigation and response to health concerns.
The Report of Suspected Child Abuse or Neglect form is also similar in that it requires detailed reporting of sensitive information. While it addresses a different area of public health, both forms are designed to ensure the safety and well-being of vulnerable populations. They both require healthcare providers to report specific incidents to the appropriate authorities for further investigation.
For those navigating the complexities of commercial real estate, it is important to recognize the significance of the Florida Commercial Lease Agreement form, which details the terms and conditions of leasing commercial property. This legally binding document not only safeguards the rights of landlords and tenants but also sets clear expectations for both parties involved. Understanding this agreement is paramount, and you can find more information about it through this link: floridadocuments.net/fillable-commercial-lease-agreement-form.
The Birth Defects Reporting Form serves a similar purpose in tracking congenital conditions. This form collects data on birth defects to help public health officials understand trends and develop prevention strategies. Like the Maryland form, it emphasizes the importance of accurate data collection to inform public health initiatives.
Lastly, the Cancer Registry Form is comparable as it gathers information about cancer cases diagnosed in a specific area. This form, like the Maryland Confidential Morbidity Report, collects vital patient information to monitor disease trends and improve public health responses. Both forms play a crucial role in understanding and addressing health issues within communities.