Texas HealTH sTeps - Fostercare Texas

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Abnormal Appearance Skin Visits Lead to (Mark questionnaire, other all health-care that Teeth Nose apply risk and providers, identified: describe): facilities: Genitalia Lungs Y N
Appearance Eyes Head TB questionnaire*, Neurological Mouth/throat Nose risk identified: Abdomen Extremities GI/abdomen Y N
Ears Skin Head/fontanels Psychosocial/Behavioral
*TB skin test if indicated Heart Teeth Mouth/throat Health Issues:
PPD Back Extremities Genitalia placed
Y N
Eyes Skin Findings: Parental (See back concerns/changes/stressors for forms)
Neurological in Musculoskeletal
Back Extremities family or home:
Abnormal Ears Eyes findings:
Heart/pulses Musculoskeletal
Back
Ears Lungs Musculoskeletal
Document Abnormal DEVELOPMENT:
Psychosocial/Behavioral Lead all findings: abnormal questionnaire, findings risk Health in identified: the space Issues: Hips below Y the N
table
or on Abnormal additional Use Findings: TB
of
questionnaire*, findings: standardized paper as needed. risk
tool:
identified: Y
P
N
F
*TB
ASQ*
skin test
ASQ-SE*
if indicated
PEDS*
PPD
Other:
placed
Additional: *ASQ,
(See
ASQ-SE,
back for
PEDS,
forms)
required for use as of 9/1/11
Teeth Lead # questionnaire, risk identified: Y N
The form TB contains questionnaire*, space for risk additional identified: documentation. Y N
Visual Additional: DEVELOPMENT:
*TB NUTRITION*:
Acuity skin test Screening: if indicated PPD placed
OD Breasts Additional: Use
Problems: (See / of back standardized /5 Y for Genitalia OS forms) N / tool: /5 OU / P F
Hearing Assessment:
ASQ* Checklist ASQ-SE* for Parents: PEDS* P P F F Other:
Document Subjective (See *ASQ, back the ASQ-SE, Hearing Tanner for form)
PEDS, stages Screening: required on the P for lines F use provided. as of 9/1/11
Subjective
MEDICAID
DEVELOPMENT:
Vision Screening: P P F F
*See Bright ID: Futures Nutrition Book if needed
HEALTH Newborn Use of Hearing EDUCATION/ANTICIPATORY
standardized Screening: tool: P F
GUIDANCE HEALTH PRIMARY Completion CARE GIVER:
NUTRITION*:
ASQ*
IMMUNIZATIONS
EDUCATION/ANTICIPATORY
date: ASQ-SE* (See back / for PEDS* / useful Results: Other: topics)
GUIDANCE PHONE: Problems: *ASQ, ASQ-SE, Y (See PEDS, N back required for useful for topics) as of 9/1/11
Document
INFORMANT:
HEALTH Selected Assessment: Up-to-date the EDUCATION/ANTICIPATORY
health results topics and completion addressed date in any of of the the newborn
hearing following GUIDANCE Selected test Deferred areas*: in health this -(See section. Reason: topics back Results addressed for useful may in be any topics) accessed of the at
https://www.provideraccess.tehdi.com following • School NUTRITION*: areas*: Readiness • Nutrition using a current user
name UNCLOTHED Selected • Development
and
School *See Problems: Bright
password.
Activity health Futures Y
If PHYSICAL topics N Nutrition no user
• addressed Safety Oral Book
name
Health EXAM if needed
or
in
password
any of the
has yet
following • Physical Development
been
See
established, Given
Assessment: areas*: today: Activity
growth graph
contact DTaP • Nutrition
TEHDI HAV at call HBV 512-458-7726 HIB or IPV
512-
• Physical Newborn IMMUNIZATIONS
458-7111
Meningococcal Activity Care
• Safety Parental/Maternal
ext. 2128, or contact
MMR
OZ Systems
Pneumococcal Well-Being
ASSESSMENT
at 866-427-5768
Weight: • Newborn Varicella Transition ( MMR-V •%) Safety Height: HIB-HBV ( DTap-HIB %)
option 2 *See or email: Bright Futures OzHelp@oz-systems.com Nutrition Book if needed to obtain the
BMI: ASSESSMENT
• Nutrional
Up-to-date
DPAP-IPV ( Adequacy DTaP-HB-IPV %) Heart Rate: DTaP-IPV-HIB Influenza
required
Blood
login Deferred
Pressure:
information. - Reason:
IMMUNIZATIONS / Respiratory Rate:
Standardized Temperature: ASSESSMENT
LABORATORY
sensory screenings for vision and hearing are
required Normal Given as Up-to-date part (Mark today: of here the DTaP physical if all items HAV examination, are WNL) HBV including HIB visual IPV
Up-to-date
acuity
Abnormal
and Meningococcal Deferred
Deferred
audiometric
- Reason:
(Mark- all Reason: that
screening MMR
apply and
tests
describe):
at specific Pneumococcal ages.
Visual Appearance acuity Varicella and audiometric MMR-V
Nose screening HIB-HBV tests Lungs performed DTap-HIB
during PLAN/REFERRALS
Head the
DPAP-IPV
Given checkup today: may
DTaP-HB-IPV
DTaP be Mouth/throat documented
DTaP-IPV-HIB
HAV HBV on GI/abdomen the HIB lines
Influenza
IPV
provided Skin Ordered Meningococcal or maintained today: as Teeth supplemental MMR documentation Extremities Pneumococcal in
LABORATORY
the Dental PLAN/REFERRALS
medical Eyes Varicella Referral: record. Y MMR-V Neurological HIB-HBV Back DTap-HIB
Other Ears Referral(s) DPAP-IPV DTaP-HB-IPV Heart DTaP-IPV-HIB Musculoskeletal Influenza
Documentation PLAN/REFERRALS
Up-to-date of test results received from a school vision
Dental
and Abnormal hearing Signature/title Deferred Referral: - Y Reason:
LABORATORY
program findings: or other source may replace the required
Other Referral(s)
visual
Referral(s):
Return acuity to office: or audiometric screening if conducted within
the 12 months Ordered Up-to-date prior today:
the checkup. If testing was completed
elsewhere, Return Deferred to documentation office: - Reason: of the results including the date
and the name of the provider who completed the screening
must be retained in the medical record.
Additional:
Return Signature/title to office:
Ordered today:
The Breasts actual results /5 must Genitalia be maintained /5 in the record.
Signature/title
Subjective Hearing Screening: P F
Signature/title
Subjective Vision Screening: P F
Signature/title
The HEALTH Hearing Checklist EDUCATION/ANTICIPATORY
for Parents is available on the back
of the GUIDANCE checkup form (See for reference back for for useful specific topics) ages as
an optional tool. Subjective sensory screenings through
provider
Selected
observation
health
and/or
topics addressed
informant report
in any
are
of the
documented
following areas*:
by checking the appropriate box when a visual acuity or
• School Activity • Oral Health
audiometric • Development screening test is • not Nutrition required.
• Physical Activity • Safety
ASSESSMENT
12/1/2011
PLAN/REFERRALS
ISIT CHILD DISCHARGE 7 YEAR 3 HEALTH VISIT RECORD TO 5 DAY VISIT CHILD CHILD HEALTH REC R R
– 4 –
Current Additional: Appearance
Medications:
Ears Heart Nose Back Lungs
Teeth Head #
Mouth/throat Abdomen Musculoskeletal
Skin Teeth Genitalia
Visits
Abnormal
Audiometric Eyes
to other
findings:
Screening: health-care
Neurological
providers, facilities:
Extremities
R Ears 1000Hz 2000HZ Heart 4000HZ Back
L 1000Hz 2000HZ 4000HZ Musculoskeletal
Parental
Abnormal
concerns/changes/stressors
findings:
in family or home:
Additional:
Health Teeth
Visual Acuity
# Education/Anticipatory
Screening:
Guidance OD / (See OS back for / useful OU topics) /
Psychosocial/Behavioral Health Issues: Y N
Health Findings:
Audiometric
HEALTH Education
Screening:
EDUCATION/ANTICIPATORY
Including Anticipatory Guidance is a
R Additional: 1000Hz 2000HZ 4000HZ
federally GUIDANCE required component (See back of for the useful checkup.
L Teeth 1000Hz #
2000HZ 4000HZ topics)
Audiometric
Lead questionnaire,
Selected health risk identified: Y N
Visual topics addressed in any of the
R
TB
following 1000Hz
questionnaire*,
Acuity Screening:
risk
areas*: 2000HZ
identified:
4000HZ
Y N
*TB
OD
L • 1000Hz
skin test
/
if indicated
OS /
School Readiness/Limitations
2000HZ
PPD
OU
• 4000HZ
placed
/
Nutrition
(See back for forms)
HEALTH • Personal EDUCATION/ANTICIPATORY
Hygiene
• Safety
GUIDANCE Visual Acuity Screening:
(See back for useful topics)
General
OD ASSESSMENT
categories
/
for
OS
useful
/
health education
OU /
DEVELOPMENT:
topics are
listed Use Selected in of this standardized section, health topics specific tool: addressed age-appropriate in any P of the F topics are
HEALTH EDUCATION/ANTICIPATORY
listed following ASQ* on the areas*: back ASQ-SE* of the form. PEDS* Checking Other:
box indicates that
GUIDANCE (See back for useful topics)
health *ASQ, • education School ASQ-SE, Readiness/Limitations
and PEDS, anticipatory required for guidance use as • of Nutrition 9/1/11 were provided
• Personal Hygiene
• Safety
as required. Selected There health is topics no requirement addressed to in document any of the specific
subject(s) following covered, areas*: although the provider may choose to do
NUTRITION*:
ASSESSMENT
so
Problems:
separately • School
Y
from Readiness/Limitations
N
the form. If there is a • problem Nutrition requiring an
action Assessment: PLAN/REFERRALS
• or Personal outcome, Hygiene documentation may be • Safety made in the space
provided for “Assessment” and “Plan/Referrals.”
Dental ASSESSMENT
Referral: Y
ASSESSMENT
*See Other Bright Referral(s) Futures Nutrition Book if needed
IMMUNIZATIONS
Plan/Referrals
PLAN/REFERRALS
Return to office:
Up-to-date
Dental Deferred Referral: - Reason: Y
Other Referral(s)
Beginning PLAN/REFERRALS
Given today:
at 6 months
DTaP
of age,
HAV
a dental
HBV
referral
HIB
is a required
IPV
component
Dental Referral:
of the checkup
Y
until a dental home is established
Return Meningococcal to office: MMR Pneumococcal
and Signature/title
Other may Varicella Referral(s) be documented MMR-V here HIB-HBV or with supplemental DTap-HIB
information DPAP-IPV maintained DTaP-HB-IPV in the medical DTaP-IPV-HIB record. Influenza
LABORATORY
Return to office:
The time
Up-to-date
that is recommended for a return appointment may
be Signature/title Deferred - Reason:
documented in this section. It does not have to include
the exact date but may include a time frame for the return
checkup Ordered or follow-up today: visit.
Signature/title
Signature/title
The person completing the checkup and the staff assisting
in completion of the checkup sign on the line with their title
included.
4 YEAR 4 YEAR VISIT 4 YEAR VISIT VISIT CHILD CHILD HEALTH CHILD HEALTH REC
Norm
Abnorm
Appe
Head
Skin
Eyes
Ears
Abnorm
Addition
Teeth
Audiom
R 1000
L 1000
Visual A
OD
HEALT
GUIDA
Selec
followin
• Sch
• Per
ASSE
PLAN
Dental R
Other R
Return
Signatur