IDHS: Illinois Department of Human Services



Bureau of Maternal & Child Health, Illinois Department of Human ServicesFY17 MIECHV and HFI Home Visiting: Chart Review ToolAgency:Present = XAbsent = ONot applicable = N/ASite:Program Model: ? HFI ? PAT ? EHSReviewer:Patient Case/Cornerstone NumberTotalsX0Family enrolled prior to 37 weeks gestation?DOB or Due Date of Target ChildBirth occurred preterm? Y/NPrenatalPrenatal Care start date 1st trimesterAdequate # prenatal visits from program start datePostnatal visit within 8 wks if enrolled prenatally or within 30 days postpartum if enrolled postnatallyMother seeing a practitioner with appropriate skill level to meet needsUse of alcohol, tobacco or illicit drugsScreening documented within 30 days of program enrollmentReferral if indicatedFollow-up if referral madeDomestic Violence screeningDomestic Violence Screening occurred within 6 months of program enrollment using FWV Relationship Assessment Tool or other standardized tool, and as neededReferral if indicatedFollow-up if referral madeInter-conception educationEducation provided on inter-conception care including timeliness and appropriateness of educationContraception use postpartumSelection of contraception method by 6 wks postpartumMethod in use by return of sexual activityContraception typeMaternal DepressionDepression screening : if enrolled postnatally, screening is completed by 3 months postpartum.If enrolled prenatally, 1 screening is completed prenatally, 1 screening completed postpartum, and as indicated by mother’s history and presentation, Referral if indicatedFollow-up if referral madeFamily needs identified and referred for servicesReferrals for food, shelter, clothing, education, job, car seats and other services made if indicatedFollow-up if referral madeFamily health care coverageTarget child has health insurancePrimary caregiver has continuous coverage of health insurance for at least 6 consecutive monthsInformation and linkages provided on access to health insurance, Medicaid, marketplace if indicatedBreastfeedingSupport and education providedSupportive family members includedInitiationBaby still breastfed at 6 months NutritionConnected to WIC officeAge appropriate nutrition educationWell child visitsWell child visits completed at following intervals:By 1 month1-2mo3-4 mo5-7 mo8-10 mo11-13 mo14-16 mo17-19 mo20-29 moOne well child visits occurred annually ages 3-5 yearsImmunizations3-2-2 Immunization by 12 mos4-3-3-1 Immunization by 24 mosDevelopmental Screening1 ASQ screenings at 9 months1 ASQ screenings at 18 months1 ASQ screening at 30 monthsASQ SE screening at 10-14 mosEvidence that Developmental Surveillance is completed at all other recommended Well-Child Health visits Referral if indicatedFollow-up if referral madeResults shared with medical providerCaregiver reports reading, storytelling, singing with child daily at every visitDentalRegular dental care initiated at 12 monthsChild has regular dentistMom has regular dentistPeriodic Oral Care education providedVision & HearingPeriodic Vision surveillance using age appropriate tools (ie Bright Futures, EI Vision Development Checklist)Periodic Hearing surveillance using age appropriate tools (ie Bright Futures)Referral if indicatedFollow-up if referral madeChildhood injury preventionEducation provided on prevention of injury including timeliness and appropriateness of educationDid childhood injury requiring medical treatment occur ? (Y/N)If so, did further injury prevention education occurSafe Sleep education providedCaregiver reports safe sleep recommendations are followed at every visit for the first 12 months.Emergency Room visits for non-emergency careAppropriate emergency room use for mother and childReferrals and education if indicatedMedical Care CoordinationOverall evidence of medical care coordinationComments: FY17 MIECHV and HFI Home Visiting Chart Review Tool 11-13-2016 ................
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