MSS prenatal screening tool
|[pic] |CLIENT NAME |
| | |
| MSS Prenatal Screening Tool |DATE OF BIRTH |CLIENT ID |
| | | |
|Instructions: |An * asterisk indicates a MSS clinician (CHN, RD, BHS) needs to make the final determination on a client’s risk criteria (A, B or C). |
| |After screening the client for the MSS targeted risk factors, document the date(s) in the appropriate A, B or C column for any identified |
| |criteria, sign the last page noting who made the determination and assign the level of service. |
|TARGETED RISK |DO NOT USE SHADED AREAS |RISK FACTOR CRITERIA |
|FACTOR | | |
| |A |B |C | |
|Race | | | | C. American Indian, Alaska Native or non-Spanish speaking indigenous women from the Americas (e.g.|
| | | | |women whose primary language is Mixteco, Mam, or Kanjobal, etc.) |
| | | | | C. African American or Black |
| | | | |C. Pacific Islander |
| | | | | |
|Prenatal Care | | | |Greater than or equal to (≥) 14 and less than ( ................
................
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