Infant Discharge Summary Worksheet

Maternal Infant Health Program (MIHP)

Beneficiary: First Name: Last Name: / Parent/Guardian: First Name: Last Name: / Infant Medicaid #:
Infant Date of Birth: / Infant Risk Identifier Completed On: (Date) / Birth Health Status / Number of Visits:
Substance Exposed Infant / Infant Services: Completed Date Completed: Cannot be Located Parent/Guardian Declined Services Infant Deceased
Family Moved: Yes No / Enrolled in WIC? Yes No
Medicaid Health Plan Contacted at Time of Enrollment in MIHP? Yes No / Medical Care Provider Notified at Enrollment and Discharge? Yes No
INFANT
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 Infant Interventions
Infant Health / 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
/ Seen by
Medical
Provider: / Regularly
Illness Only
Sporadic
Never
1 to 5 cigarettes
less than 1 cigarette
Location
of Medical
Provider: / Clinic/Office
ER/Urgent Care
Other
Receiving Children’s Special Health Services (CSHCS): / Yes / No
Immunization Up to Date: / Yes / No
Infant Health Education Provided: / Yes / No
Referred / Yes / No
Infant Safety / N / L / M / H / U
R
S
HI
/ H
E / None
None / Partial
Partial / All
All / Refused
Refused
/ Sleeps on Back / CPS Referral:
Sleeps with Someone / Current Open CPS Case:
Car Seat / Infant Safety Education Provided:
Lead Risk / Referred
2nd Hand Smoke
Infant Breastfeeding / N / L / M / H / U
R
S
HI
/ M
H
E / None
None
None / Partial
Partial
Partial / All
All
All / Refused
Refused
Refused
/ Breastfeeding Initiated: / Yes / No
Breastfeeding Duration / Less than 1 week
Between 1 week and 1 month
More than 1 month
Infant Feeding and Nutrition / N / L / M / H / U
R
S
HI
/ M
H / None
None / Partial
Partial / All
All / Refused
Refused
/ Infant Primarily Fed: / Breast Milk / Formula / Solid food / Other
Ever Breast Fed: / Yes / No
If yes, How Long: / Days / Weeks / Months
Sleeps with Bottle: / Yes / No
Plans for Dentist: / Yes / No
Receiving WIC Services: / Yes / No
Feeding and Nutrition Education Provided: / Yes / No
Feeding and Nutrition Education Referred: / Yes / No
INFANT - Continued
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 Infant Interventions
Infant Development / N / L / M / H / U
R
S
HI
/ M / None / Partial / All / Refused
/ Referred by MIHP to Early On®: / Yes / No
Receiving Early On® Services: / Yes / No
Infant Development Education Provided: / Yes / No
Referred / Yes / No
Infant
Family Support / N / L / M / H / U
R
S
HI
/ M
H
E / None
None
None / Partial
Partial
Partial / All
All
All / Refused
Refused
Refused
/ Identify Minimum of 1 Support Person: / Yes / No
Immunization Up to Date: / Yes / No
Infant Health Education Provided: / Yes / No
Referred / Yes / No
MATERNAL CONSIDERATIONS
Maternal 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
Chronic Disease Follow Up Plan in Place: / Yes / No
Referred: / Yes / No
Maternal
Smoking / N / L / M / H / U
R
S
HI
/ M / None / Partial / All / Refused
/ Smokes: / More than 1 to1.5 packs
1 to 1.5 packs
.5 to 1 packs
6 to 10 cigarettes
1 to 5 cigarettes
less than 1 cigarette
Tobacco Cessation Education Provided / Yes / No
Referred / Yes / No
In Cessation Program / Yes / No
Refused Assistance / Yes / No
Maternal Alcohol / N / L / M / H / U
R
S
HI
/ M
H
E / None
None
None / Partial
Partial
Partial / All
All
All / Refused
Refused
Refused
/ Currently Consumes:
14 Drinks or More a Week / Alcohol Use Education Provided / Yes / No
7-13 Drinks a Week / Referred / Yes / No
4-6 Drinks a Week / In Treatment
1-3 Drinks a Week / Refused Assistance
Less than 1 Drink a Week
Refused
MATERNAL CONSIDERATIONS - Continued
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 Infant Interventions
Maternal Drugs / N / L / M / H / U
R
S
HI
/ M
H
E / None
None
None / Partial
Partial
Partial / All
All
All / Refused
Refused
Refused
/ Current Drug Use:
Quit
. Decreased
Same level
Increased
Refused
Drug use Education Provided / Yes / No
Referred / Yes / No
In Treatment
Refused Assistance
Maternal Stress
Depression / N / L / M / H / U
R
S
HI
/ L
M
H
E / All
All
All
All / Partial
Partial
Partial
Partial / None
None
None
None / Refused
Refused
Refused
Refused
/ Education Provided / Yes / No
Referred / Yes / No
In Treatment / Yes / No
Refused Assistance / Yes / No
Maternal Abuse / Violence / N / L / M / H / U
R
S
HI
/ M
H
E / All
All
All / Partial
Partial
Partial / None
None
None / Refused
Refused
Refused
/ In Current Domestic Violence Relationship / Yes / No / Unknown
DV Education Provided: / Yes / No
Referred / Yes / No
Maternal
Housing / N / L / M / H / U
R
S
HI
/ M
H
E / All
All
All / Partial
Partial
Partial / None
None
None / Refused
Refused
Refused
/ Stable / Yes / No
Safe / Yes / No
Homeless / Yes / No
Housing Education Addressed: / Yes / No
Referred / Yes / No
Maternal
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
SUBSTANCE EXPOSED INFANT /
Key:
/ I =
S =
N =
L=
M =
H = / Initial Identified Risk
Summary
None
Low
Moderate
High / P =
C =
Pr =
A =
M =
R = / Pre-contemplation (Ignorance is Bliss)
Contemplation (Sitting on the Fence)
Preparation (Testing the Waters)
Action (Ready to Go)
Maintenance (Still going Strong)
Relapse (Slip//Fall from Grace) / L = Low
M = Moderate
H = High
E = Emergency
/
Domain / Risk / Risk / Interventions Provided / Progress During Infant Interventions /
Substance Exposed Infant:
Positive
at Birth / N / L / M / H
I
S
/ P / C / Pr / A / M / R
I
S
/ L
M
H
E / None
None
None
None / Partial
Partial
Partial
Partial / All
All
All
All / Refused
Refused
Refused
Refused
/ Received information and discussed effect of prenatal exposure to drug(s) and/or alcohol on infant including potential developmental outcomes.
Received information on resources available to substance exposed infants. /
Substance Exposed Infant:
Primary Caregiver / N / L / M / H
I
S
/ P / C / Pr / A / M / R
I
S
/ L
M
H
E / None
None
None
None / Partial
Partial
Partial
Partial / All
All
All
All / Refused
Refused
Refused
Refused
/ Received information and discussed effect of Mom/Primary Caregiver’s drug and/or alcohol use on infant health and development.
Received information on maintaining infant safety when Mom/Primary Caregiver is using substances in the infant’s environment. /
Substance Exposed Infant:
Environment / N / L / M / H
I
S
/ P / C / Pr / A / M / R
I
S
/ L
M
H
E / None
None
None
None / Partial
Partial
Partial
Partial / All
All
All
All / Refused
Refused
Refused
Refused
/ Received information and discussed effect of drug and/or alcohol use by people other than Mom/Primary Caregiver on infant health and development.
Received information on maintaining infant safety when others are using substances in the infant’s environment. /
Infant Education:
Group Parenting Education: / Provided / Referred / NA
Group Parenting Education Attended? / Yes / No / Unknown / Refused
Currently Breastfeeding? / Yes / No / Unknown
Immunization Schedule: Education Provided / Yes / No
Immunization Schedule: Education Referred / Yes / No
Immunization Schedule: Education Refused / Yes / No
Well Child Schedule: Education Provided : / Yes / No
Well Child Schedule: Education Referred / Yes / No
Well Child Schedule: Education Refused : / Yes / No
/
Referrals Made During Care
Family Planning / Counseling / Substance Abuse Services / Child Care
Immunizations / Infant Mental Health / Child Protective Services (CPS) / Parenting Support
Medical / Home Visitation/Support Program / Describe: / Domestic Violence Services / Other Referrals / Describe:
Dental / WIC
/
Additional Comments: /
Name of Professional Completing Summary: / Social Worker
Registered Nurse
Professional Credentials: / Date: /

I200

Effective 10/1/14