Echocardiogram Result Report
Pulse Oximetry (CCHD) Screening
This form should be used to report to the MDH Newborn Screening Program:
• All newly diagnosed cases of Critical Congenital Heart Disease
Reportable conditions: coarctation of the aorta, double outlet right ventricle, Ebstein’s
anomaly, HLHS, interrupted aortic arch, pulmonary atresia, TAPVR, TOF, transposition
of the great arteries, tricuspid atresia, truncus arteriosus, single ventricle (not otherwise
specified)
• All echocardiograms done as follow-up to failed Pulse Oximetry Screens
Patient Information:
Name:
DOB:
Mother’s Name (if newborn):
Infant’s Hospital:
Referring/Attending/Ordering Physician:
Transfer Information (if applicable):
Please Choose
Transferred to UMN
Unknown
Avera Clinic
CentraCare
Children's
Mayo
Sanford
Masonic
Sioux
Fargo
Hospital
St.
Falls
Cloud
Children's
and
Hospital
Clinics
Hospital
of MN
Echocardiogram Information:
Facility Interpreting Echocardiogram:
Cardiologist Interpreting Echocardiogram:
Date of Echocardiogram:
Echocardiogram Results:
Please choose
Diagnosis:
Coarcation
Normal
Ebstein's
Double
Hypoplastic
Interrupted
Pulmonary
Total
Tetralogy
Transposition
Tricuspid
Trucus
Single
Non-critical
Other
Anomalous
(please
ventricle
Arteriosus
outlet
anomaly
of
Atresia
of
Atresia
aortic
Left
Fallot
malformation
describe):
the
right
of(not
Heart
the
aorta
Pulmonary
arch
ventricle
otherwise
Great
Syndrome
Arteries
Venous
specified)
Return
Please
choose
Critical(Please
Normal
Delayed
Non-Critical
Pneumonia
Other
Sepsis
Respiratory
Congenital
Transition
Congenital
describe):
Disease
HeartHeart
Disease
Disease
Minnesota Newborn Screening Program
Phone: (800) 664-7772
Fax: (651) 215-6285