ILLINOIS DEPARTMENT OF HUMAN SERVICES



Illinois Department of Human ServicesHWIL Chart Review: 0-5 Years & Pregnant Youth in Care FY18Agency:Site:Response Codes: PresentAbsentNot Applicable===XON/ADate:MCH Nurse Consultant:Cornerstone NumberTotalsType of File (P, I, C) and AgeXODate of BirthProfile: PA02Name, Address, PhoneAssigned Case ManagerEnrollment: PA03Pregnancy (Y/N)Race, ethnicity, sexHWIL Primary Care ProviderCurrent servicesProgram Info PA15Program statusHWIL initiation date [F8 Program HX]Initial Contact in 48 hours (SV02)Transfer in from another MCMA? Date:Medical ScreensPA11: BirthAPORS Infant (Y/N)Birth WeightPA13-14: Immunizations PA07: Initial Prenatal (List EDC)PA08: Adult Health -smoking interventionPA07&10: # Prenatal VisitsSV01?: 941-942 RLPSV01: PEWW Interconception EdAssessments AS01:0-5 years700 Q43-51: General - Annually 708 A-R: Anticipatory Guidance 712: Risk Assessment (Infant of Parenting Youth in Care only)Assessments AS01:Pregnant Youth in Care700Q1-22, 26: General Annually 710: Prenatal Ed or BBO Policy711: Prenatal Risk Assessment707G: BBO Risk Assessment 708Q81: Nutrition or PA15 WICSV01:825 Depression ScreeningPrenatalPostpartumCare Plan:CM02-03CM02: Goals CM03: Planned Services Referrals and Follow-up: RF01-03814: EI if indicated by dev screen or other health provider (PA15, F2 to)819: WIC if appropriate822: Specialist if indicated906: DCFS Nurse if medically complex907: APORS or HRIF if eligibleDSCC Referral if medically complex804: Family Planning Other Referrals: ListVerify with SCG receiving servicesMedical Needs IdentifiedHWLA IMCM records on fileComp Health Profile 5.1 or CHE form (CFS 653) Health Summary (CFS 497IIID)Past medical records or attemptsIA Summary sent to PCPSCG contactedSV01: 806 or 802 - EPSDT age appropriate or prenatal visitsSV01:827 Dental 2y & prophylaxis q. 6 moSV01:828 Vision 3, 4 & 5 ySV01:829 Hearing 4 & 5yHealth Summary Form for ACR or TransferPA19: ACR Cycle (list months)SV02: Health Summary sent to Caseworker a month prior to ACR every 6 monthsSV02: Transfers: Sent to new MCMA and /or HWLA and Caseworker if transferred-842645295465500Case Closure (if YES, complete)SV02: Health Summary Transfer Form sent to Caseworker and HWLA at age 6 (Cook Co: sent to HWLA)PA15: Reason for Closure Sources for continued servicesReport of Prenatal Care Services & Pregnancy Outcomes sent to HWLA – [Cook Co only]*EPSDT well child visits for 9, 12, and 24 months include required hearing and vision screening as part of the physical exam of ears and eyes and developmental mentsCase NumberReviewer CommentsFY18 HWIL Chart Review: 0-5 Years & Pregnant Youth in Care 5-23-2017 ................
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