Maternal Infant Health Program

MATERNAL Discharge Summary Worksheet

Maternal Infant Health Program (MIHP)

Beneficiary Name: / Medicaid #: / SS#: / Date of Birth:
Maternal Risk Identifier Completed Date: / EDC (Due Date): / Delivery Date:
Birth Outcome: / Live Birth / Still Birth / Miscarriage / Elective Abortion / Other
Infant Followed in MIHP? YesNo / Maternal Services Completed? : Yes, Prior to birth Yes, After the birth / Date Completed:
Number of Prenatal Visits: / Number of Postnatal Visits: / Medicaid Health Plan Contacted at Time of Enrollment in MIHP? Yes No
Medical Care Provider Notified at Enrollment and at Discharge? Yes No / Enrolled in WIC? Yes No
MATERNAL
The Following Chart Addresses the Initial Risk(s) Identified at Enrollment in MIHP and Current or Ongoing Risk(s)
KEY: / R = Initial
S = Summary
HI = Highest Interim / N = No
L = Low
M = Moderate
H = High
U =Unknown / L = Low
M = Moderate
H = High
E = Emergency
Domain / Risk / Interventions Provided / Progress During Maternal Interventions
Family Planning / N / L / M / H / U
R
S
HI
/ L
M / None
None / Partial
Partial / All
All / Refused
Refused
/ Method Identified / Yes / No
Plan in Place / Yes / No
Education Provided / Yes / No
Referred / Yes / No
Pregnancy
History / N / L / M / H / U
R
S
HI
/ M
H
E / None
NoneNone / Partial
Partial
Partial / All
All
All / Refused
Refused
Refused
/ Entered Prenatal Care Prior to 14 Weeks
Entered Prenatal Care At or Beyond 14 Weeks
Food / N / L / M / H / U
R
S
HI
/ //
M / None / Partial / All / Refused
/ Food Adequate / Yes / No
Nutrition Risks Addressed / Yes / No
Food Education Provided / Yes / No
Referred / Yes / No
Housing / N / L / M / H / U
R
S
HI
/ M
H
E / None
None
None / Partial
Partial
Partial / All
All
All / Refused
Refused
Refused
/ Stable / Yes / No
Safe / Yes / No
Homeless / Yes / No
Housing Education Addressed / Yes / No
Referred / Yes / No
Transportation / N / L / M / H / U
R
S
HI
/ M / None / Partial / All / Refused
/ Adequate / Yes / No
Transportation Education Provided / Yes / No
Referred / Yes / No
Social Support / N / L / M / H / U
R
S
HI
/ M
E / None
None / Partial
Partial / All
All / Refused
Refused
/ Identify at least 1 Support Person / Yes / No
Social Support Education Provided / Yes / No
Referred / Yes / No
Nutrition / N / L / M / H / U
R
S
HI
/ L
M
H / None
NoneNone / Partial
Partial
Partial / All
All
All / Refused
Refused
Refused
MATERNAL
The Following Chart Addresses the Initial Risk(s) Identified at Enrollment in MIHP and Current or Ongoing Risk(s)
KEY: / R = Initial
S = Summary
HI = Highest Interim / N = No
L = Low
M = Moderate
H = High
U =Unknown / L = Low
M = Moderate
H = High
E = Emergency
Domain / Risk / Interventions Provided / Progress During Maternal Interventions
Breastfeeding / N / L / M / H / U
R
S
HI
/ L
M
H / None
NoneNone / Partial
Partial
Partial / All
All
All / Refused
Refused
Refused
/ Breastfeeding Initiated: / Yes / No / Unknown
Breastfeeding Duration: / Less than 1 week
Between 1 week and 1 month
More than 1 month
Smoking
2nd Hand Exposure / N / L / M / H / U
R
S
HI
/ M / None / Partial / All / Refused
/ Smoked: / More than 1 to1.5 packs / Smokes: / More than 1 to1.5 packs
1 to 1.5 packs / 1 to 1.5 packs
5 to 1 packs / .5 to 1 packs
6 to 10 cigarettes / 6 to 10 cigarettes
1 to 5 cigarettes / 1 to 5 cigarettes
less than 1 cigarette / less than 1 cigarette
Tobacco Cessation Education Provided / Yes / No
Referred / Yes / No
Alcohol / N / L / M / H / U
R
S
HI
/ M
H
E / None
NoneNone / Partial
Partial
Partial / All
All
All / Refused
Refused
Refused
/ During Pregnancy Consumed: / Currently Consumes:
14 Drinks or More a Week / 14 Drinks or More a Week
7-13 Drinks a Week / 7-13 Drinks a Week
4-6 Drinks a Week / 4-6 Drinks a Week
1-3 Drinks a Week / 1-3 Drinks a Week
Less than 1 Drink a Week / Less than 1 Drink a Week
Alcohol Use Education
Provided / Yes / No / Alcohol Use Education
Provided / Yes / No
Referred / Yes / No / Referred / Yes / No
In Treatment / In Treatment
Refused Assistance / Refused Assistance
Drugs / N / L / M / H / U
R
S
HI
/ M
H
E / None
None
None / Partial
Partial
Partial / All
All
All / Refused
Refused
Refused
/ During Pregnancy Drug Use: / Current Drug Use:
Quit / Quit
Decreased / . Decreased
Same level / Same level
Increased / Increased
Drug use Education Provided / Yes / No / Drug use Education Provided / Yes / No
Referred / Yes / No / Referred / Yes / No
In Treatment / In Treatment
Refused Assistance / Refused Assistance
Stress/Depression / N / L / M / H / U
R
S
HI
/ L
M
H
E / None
None
None
None / Partial
Partial
Partial
Partial / All
All
All
All / Refused
Refused
Refused
Refused
/ Education Provided / Yes / No
Referred / Yes / No
In Treatment
Refused Assistance
MATERNAL
The Following Chart Addresses the Initial Risk(s) Identified at Enrollment in MIHP and Current or Ongoing Risk(s)
KEY: / R = Initial
S = Summary
HI = Highest Interim / N = No
L = Low
M = Moderate
H = High
U =Unknown / L = Low
M = Moderate
H = High
E = Emergency
Domain / Risk / Interventions Provided / Progress During Maternal Interventions
Abuse/Violence / N / L / M / H / U
R
S
HI
/ M
H
E / None
None
None / Partial
Partial
Partial / All
All
All / Refused
Refused
Refused
/ In Current Domestic Violence Relationship / Yes / No / Unknown
Referred / Yes / No
Domestic Violence Education Provided / Yes / No
Referred / Yes / No
Asthma / N / L / M / H / U
R
S
HI
/ L
M
E / None
None
None / Partial
Partial
Partial / All
All
All / Refused
Refused
Refused
/ Asthma Education Provided / Yes / No
Referred / Yes / No
Diabetes
Type 1, 2
and Gestational / N / L / M / H / U
R
S
HI
/ L
M
E / None
None
None / Partial
Partial
Partial / All
All
All / Refused
Refused
Refused
/ Diabetes Education Provided / Yes / No
Referred / Yes / No
Hypertension / N / L / M / H / U
R
S
HI
/ L
M
E / None
None
None / Partial
Partial
Partial / All
All
All / Refused
Refused
Refused
/ Hypertension Education Provided / Yes / No
Referred / Yes / No
Maternal Summary / Group Childbirth Education:
Provided
Referred
NA
Group Childbirth
Education Attended: / Yes / No / Unknown / Refused
/ Currently Breastfeeding? / Yes / No / Unknown
Infants Birth Weight: / lbs. / oz.
Infants Gestation Age: / < =37 Week / > 37 Weeks
Immunization Schedule: / Well Child Schedule:
Education Provided / Education Provided
Referred / Referred
Refused / Refused
Family Planning / Substance Abuse Services
Medical / Child Protective Services
Dental / Domestic Violence Services
Counseling / WIC
Basic Needs / Child Care
Infant Mental Health / Baby Items
Home Visitation/Support / Education
Describe: / Employment
Other Describe:
Referrals Made During Care:
Additional Comments:
Name of Professional Completing Summary: / Social Worker
Registered Nurse
Professional Credentials: / Date:

M200

Effective 10/1/14