Perinatal Risk Assessment Discharge Tool

Patient Name: ______MR#: ______

Risks / Risk Categories / Interventions / SignatureDate
Initiate / Complete
Problem Medications /  Adherence/complications
 Anticoagulants
 Anti-depressants/Psychotropic
medications
 Insulin
 Methadone/Long term narcoticsuse
 Oral hypoglycemic agents
 Polypharmacy
 Other problem medications / (1, 2, 3, 4, 5)
(1, 2, 3, 4, 5)
(1, 2, 3, 4, 5)
(1, 2, 3, 4, 5)
(1, 2, 3, 4, 5)
(1, 2, 3, 4, 5)
(1, 2, 3, 4, 5)
(1, 2, 3, 4, 5, 6) /
  1. Post-discharge phone call within:  24 - 72hrs
  2. Discharge summary communicated to OB/GYN and/or PCP:
     Fax  Mail/Email
  3. Medication specific strategies (RN or pharmacist)
 Communicate monitoring plan to patient/caregiver
 Review (applicable) medication/monitoring plan
 Teach using “Teach Back” method
  1. Review specific strategies for managing adverse drug events
  2. Out-Patient follow-up/referrals (check all that apply)
 Cardiology  Endocrine
 Home Health Visit  Mental Health
 WIC Referral
 Medical Evaluation within 2 weeks
  1. Other (specify)______

Maternal
Medical Risks /  Asthma/Pulmonary Disease
(RequiringMedication within the last
90 days and/or at discharge)
 BMI < 18.5 or > 40
 Chronic Hypertension:
pre-pregnancy
DVT/Thromboembolism (TE)
 Physical Disability
Sickle Cell Disease/
hemoglobinopathy
 Other Medical Conditions (specify)
______/ (1, 2, 3, 4, 5, 6, 7)
(1, 2, 4, 5, 6, 7)
(1, 2, 3, 4, 5, 6, 7)
(1, 2, 3, 4, 5, 6)
(2, 4, 7)
(1, 2, 3, 4, 5, 6, 7)
(1, 2, 3, 4, 5, 6, 7, 8) /
  1. Post-discharge phone call within: 24 - 72hrs
  2. Discharge summary communicated to OB/GYN and/or PCP:
 Fax  Mail/Email
  1. Medication specific strategies
 Communicate monitoring plan to patient/caregiver
 Review (applicable) Medication/Monitoring plan
 Teach using “Teach Back” method
  1. In-Patient Consults (check all that apply):
 Cardiology  Dietary/Nutrition
 Endocrine  Mental Health
 Respiratory  Social work
  1. Out-Patient follow-up/referrals (check all that apply)
 Cardiology  Endocrine
 Home Health Visit  Mental Health
 WIC Referral
 Medical Evaluation (within 2 weeks)
  1. Teaching (risk-specific teaching)
  2. DHMH Referral form completed
  3. Other (specify)______

Risks / Risk Categories / Interventions / SignatureDate
Initiate / Complete
Pregnancy-
Related Risks /  Age < 18
 Age > 40 & primigravida
 Diabetes
 Gestational Diabetes
 Insulin Dependent Diabetes
 Pregestational Diabetes
 Requiring Medication at
Discharge
 At risk for DVT/
Thromboembolism (TE)
 Hypertensive Disorders
 Chronic Hypertension
 Gestational Hypertension
 Pre-eclampsia/Eclampsia
 Late/Inadequate/No Prenatal
Care (< 5 visits)
 Positive Toxicology Screen
 Sexually Transmitted Infection/
Human Immunodeficiency
Virus/Hepatitis
 Other Pregnancy or delivery-
related risks Specify______/ (1, 2, 3, 4, 5, 6, 7)
(1, 2, 3, 4, 5, 6, 7)
(1, 2, 3, 4, 5, 6, 7)
(5, 6)
(1, 2, 3, 4, 5, 6, 7)
(2, 5,6 )
(1, 2,3, 4, 5, 6, 7)
(2, 3, 5, 6,7)
(1, 2, 3, 4, 5, 6, 7, 8) /
  1. Post-discharge phone call within:  24 - 72hrs
  2. Discharge summary communicated to OB/GYN and/or PCP:
     Fax  Mail/Email
  3. Medication Specific Strategies (as applicable)
 Communicate monitoring plan to patient/caregiver
 Review medications/Monitoring plan
 Teach using “Teach Back” method
  1. In-Patient Consults (check all that apply):
 Cardiology  Dietary/Nutrition
 Endocrine  Mental Health
 Respiratory  Social work
  1. Out-Patient follow-up/referrals (check all that apply):
 Cardiology  Endocrine
 Home Health Visit  Mental Health
Medical Evaluation (within 2 weeks)
  1. Teaching (risk- specific teaching)
  2. DHMH Referral Form Completed
Other (specify)______