Texas HealTH sTeps - Fostercare Texas

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s: s: e: e: e: PV l -HIB nza e: 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
Back of forms The back of each form includes age-appropriate Health Education and Anticipatory Guidance and modified versions of screening questionnaires. Typical Developmentally Appropriate Health Education Topics The health topics included in the list for each age group are age-specific. No notation is required on the back of the form; only the check in the box on the front of the form is required. Reference materials may be found at http://brightfutures.aap.org/. Hearing Checklist for Parents (optional) TB Questionnaire LEAD RISK FACTORS 02/2012 – 5 –
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