Initial Combined Assessment (ICA) - Department of Public Health

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Patient: Patty Preggers Gravida: 1 Para: 0 EDC: May 1, 200934Provider Name: Dr Le BronCase Coordinator: Sarah Smart, CPHWProvider Signature: Date: 2/08/09Date:12/20/08StrengthsIdentified:__Motivated to seedentistIdentifiedProblem /Risk/Concern#30. Has not beento dentist withinpast year becauseof lack ofinsuranceTeaching/ Counseling/Referral-CPHW reviewed/discussed STT HE p. 47“Oral health duringPregnancy”.- CPHW referred pt todentist (denti-cal provider)HAPPY DENTAL(323)2221111Follow-upReassessmentDate-Outcome/Plan2/08/09-Pt did not go to dentistappt because she statesthat she didn’t feel well.Pt will go to dentist bynext prenatal appt.Follow-upReassessmentDate-Outcome/Plan4/26/09- Pt went to dentistappt 3/9/09 and statesthat she has nocavities-Problem resolvedGoal:Will go to dentistby next prenatalvisitDate:12/20/08StrengthsIdentified:__-willing to discussproblems inrelationship- willing to providesafe environmentfor self/babyDate:12/20/08StrengthsIdentified:__Encouraged tolearn aboutbreastfeedingWill @ least try tobreastfeed#102 Feelsthreatened byboyfriendGoal:Pt will feel safeimmediately#89 Plan to breastfeed/formula feedbecause will returnto work in 6 weeks.Goal:To understandbenefits ofexclusivelybreastfeeding bynext prenatal visit-CPHW informed pt oflimits of confidentiality-CPHW reviewed/discussed STT Psych p.53-55 ”Spouse/Partnerabuse”-CPHW referred pt to SW,Wilma Ward, (323)8675309 scheduled appt12/30/08-CPHW informed MD.-referred to Women’sshelter (323) 445-5694-referred to domesticviolence hotline (800) 456-1111- CPHWreviewed/discussed STTHE p. 99-100”InfantFeeding Decision making”- CPHWreviewed/discussed STTNutrition” How to getStarted Making plenty ofMilk”- CPHW reviewed Ptconcerns related to returnto work (I. E Breast pumps)-Pt met with SW(12/30/08) See SWnotes.- Pt states broke up withboyfriend lastmonth/feeling okay &safe. Denies seeingboyfriend- Pt consideringexclusively breastfeedingbut is worried about milksupply- CPHW enc. Pt to attendWIC breastfeedingclasses; WIC (323)3124444-Pt states she nolonger has contact withboyfriend-Problem resolved-Pt agrees toexclusively breastfeedfor at least first 4weeks.-CPHW referred pt toLa Leche League(800) 9999999- CPHW to schedulereturn to clinic apptafter pt d/c fromhospital to evaluatebreastfeeding
Date:12/20/08StrengthsIdentified:__Willing to receivetreatmentConcerned abouthealth & baby’shealthIdentifiedProblem /Risk/ConcernLab test positivefor ChlamydiaGoal:To receivetreatment todayTeaching/ Counseling/Referral-Dr LeBron treated ptAzithromycin 1gm POStrongly advised to tellboyfriend to come to clinicfor treatment- CPHWdiscussed/reviewed STTHE p23-25 “STDs”- MD advised to refrainfrom sex for 2 weeks.Follow-upReassessmentDate-Outcome/Plan-T.O.C. negative-Per pt: left msgs forboyfriend to call backbut no response.-Per MD ordersadvised to practicesafer sex.- Problem resolved35Follow-upReassessmentDate-Outcome/Plan-Pt states nocomplaints
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Initial Combined Assessment (ICA) - Department of Public Health

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