INFANT/CHILD (0-2 years 11months) ASSESSMENT/ INTERVENTION/ PLAN
______o Initial Assessment (***) = Required at EACH visit
Last Name: First Name: o Interim Assessment
Date of Birth:______o ICHAP Registration (*Required ICHAP Registration data)
Date of Visit:______o ICHAP Assessment (**Required ICHAP Assessment data)
Reporting pd.(months) o 6 o 12 o 24 o 36
(****)Reason for Foster Care Placement:
(****)Date of Placement:
(****)Status of Siblings: If child in foster care, complete items with an (****)
HEALTH STATUS
HEALTH HISTORY
Gestational Age: ______weeks
Illnesses:______
Other: ______
Current Health:______Hospitalization ______
Allergies:
History of Asthma o Y o N
If asthmatic, has: Medications o Y o N, Nebulizer o Y o N,
Peek Flow Meter o Y o N
ICHAP DATA (*) Only complete this section at ICHAP enrollment
*County of Birth: Specify)______
*Plurality (single, twins) o 1 o 2 o 3 o 4
*Birth order (multiple births) o 1 o 2 o 3 o 4
*Race o White(W) o Black(B) o Asian(A)
o Native Amer (N) o Unknown (U)
*Ethnicityo Hispanic (HP)oNot Hispanic (NH)oUnknown (NS)
NUTRITION
o Breast o Formula-Type:______o Both o Cup
Frequency: Every ______hours
______ozs. of formula at every feeding
______minutes at each breast for each feeding
Parent verbalizes knowledge of formula preparation
o Y o N o N/A
Parent aware of importance of holding infant at
feedings in proper position o Y o N o N/A
Solids o Cereal o Fruits o Vegetables
o Meats o Table foods
If solids, on spoon o Y o N If solids, in bottle o Y o N
Juice o Y o N If yes,(specify)______
Food allergies? o Y o N(specify)______
o For FTT only, kept daily food log o Y o N
PARENT/CHILD INTERACTION (describe as indicated): ______
______
PREVENTIVE HEALTH PRACTICES
Has pt changed ins since last vs? o Y o N
Interval Since Last MD Visit:______
Plan for MD visit: Date______MD Name:
(****) Child’s MD prior to foster placement: ______
Other: (specify)______
o Y o N:MD did child’s developmental screen? Date______
Parent verbalizes knowledge of S/S illness:
Fever o Y o N Respiratory Pb o Y o N
Vomiting o Y o N Diarrhea o Y o N
Rash o Y o N Listlessness o Y o N
Parent verbalizes: s/s hydration o Y o N
when to notify MD o Y o N
Parent demonstrates how to take temp o Y o N
Parent has thermometer o Y o N
Dental Care ______
SAFETY
Age related hazards o Y o N
(specify)______
Has car seat o Y o N
ELIMINATION
______# of wet diapers per day
______# of bowel movements per day
color: o Normal o Other (specify) ______
consistency: o soft o hard o watery
o other (specify) ______
When applicable, toilet training efforts o Y o N
When applicable, toilet training problems o Y o N
(specify)______
______
Other (specify):______
SLEEP
o Y o N Sleep pattern nl for age. If no, specify:______
PHYSICAL EXAMINATION
FONTANEL
Anterior WNL o Y o N o N/A
Posterior WNL o Y o N o N/A
Other (specify)______
LUNGS
Clear bilaterally o Y o N
Retractions o Y o N
Other ______
UMBILICAL STUMP
Present o Y o N o N/A
Redness o Y o N
Exudate o Y o N
SKIN
Rash o Y o N
Turgor poor o Y o N Other:______
COLOR
Normal o Y o N
Icteric o Y o N
Pale o Y o N
Cyanotic o Y o N
Other ______
ABDOMEN
Soft o Y o N
Distended o Y o N
Bowel sounds o Y o N
Apical Pulse______Resp.______
BP (if appropriate)______
CIRCUMCISIONo Y o N o N/A
Redness o Y o N o N/A
Edema o Y o N o N/A
PERINEUM
Erythema/Edema o Y o N
Rash o Y o N
NEUROLOGICAL
Alert o Y o N
Reflexes Rooting o Y o N o N/A
Startle o Y o N o N/A
Suck o strong o weak o N/A
Flexion o Y o N o N/A
Other______
Temp: ______
o Entered in KIDS: DATE/INITIALS
______
DEVELOPMENTAL MILESTONES (As per DDST II parameters - adjusted for gestational age)
Personal/Social o Age appropriate o Other (specify) ______
Fine Motor o Age appropriate o Other (specify) ______
Language o Age appropriate o Other (specify) ______
Gross Motor o Age appropriate o Other (specify) ______
**DDST II Results o Normal(N) o Suspect(S) o Abnormal(A)
**IMQ Results o Normal(N) o Suspect(S) o Abnormal(A)
___Communication ___Gross Motor ___Fine Motor ___Adaptive ___Psycho/Social
**ANTHROPOMETRIC ASSESSMENT Birth Weight:_____ lbs. _____ ozs. /_____ gms.
Date of assessment: ______
Length/Height: ______inches ______percentiles
Weight: _____ lbs. _____ ozs. /_____ gms. ______percentiles
Head Circumference: ______inches ______cm. ______percentiles
Growth in comparison with normal: o Normal o Over o Under
For FTT only: ____hours since last feeding; Last diaper chg______, Last BM______
(*)REASONS FOR ICHAP ENROLLMENT (CIRCLE THE LETTER OF UP TO THREE REASONS)
(B) Asphyxia (Apgar score of 3
or less at five minutes)
(C) Birth Weight <1501 GMS
(E) Central nervous system
insult/abnormality
(F) Congenital Anomaly (MAJOR)
(G) Congenital/Perinatally
Transmitted Infection (HIV, Syphillis)
(J) Gestational age < 33 weeks
(K) Growth deficiency/ nutritional pb
(L) Hepatitis B (mom + HBsAg)
(N) Hyperbilirubinemia
(>20 mg/dl)
(O) Other: ______
(P) Hypoglycemia (Serum Glucose
under 20 mg/dl)
(Q) Inborn Metabolic Disorder(IMD)
(R) Elevated lead level (³20 mg/dl)
(V) Maternal PKU
(W )Maternal Prenatal ETOH Abuse
(X )Maternal Prenatal Drug Abuse
(Y )Muscle tone abnormalities
(hyper-or hypotonicity)
(Z) NICU (10+ Days)
(1) Otitis media(chronic serous)
(5) Parental Substance Abuse
(6) Respiratory distress
(7) Suspected developmental delay
(8) Suspected hearing impairment
(9) Suspected visual impairment
ADDITIONAL FINDINGS:
(***) ABNORMAL FINDINGS NOTED DURING VISIT: o yes o no If yes describe:
Action taken: Time of action taken______(am or pm)
Follow up plan:
INTERVENTION/EDUCATION AND COUNSELING PARAMETERS
o Developmental milestones
o (****)Importance of “medical home”
o Instruction in parenting/age approp discipline
o (****)Strategies to integrate child into the family (for example: age appropriate responsibilities, etc.)
o Age approp activities/importance of reading to child
o Instruct feeding positions
o Instruction in child care
o Toilet training strategies
o Age appropriate activities
o Age appropriate safety measures
o Seat belt/car seat use
o Well child health care schedule
o Immunization schedule and S/E (specify in plan if
not upto date)
o For food borne illness,o etiolo transm mode
o s/s infection o incubation pd o prevention
o food prep o specimen collection o info sheet
o S/S and management childhood illness
o Nutritional guidelines
o Breastfeeding instruction
o Formula/food preparation
o Hygiene
o Reviewed o’Keeping Cool’ o How I Grow
o What to expect when baby is preterm
o When your child is sick
oOther:______
PLAN
o Referral to:(specify)______
o Education as per listed parameters
o If immunizations not up to date, specify plan:
o Other:
Y N
o o Patient verbalized understanding instructions
o o Patient/caretaker participated in developing care
plan and agrees with same
If no, specify reason:______
o To be discharged when all goals are met
If Initial Plan or change in plan, nurse’s plan for revisiting: Freq.______duration______
Date of Next Visit: ______
Signature: