CPSP Multi-Chart Review Tool - CDPH Home



CPSP Provider:_______________________________________________________Date:__________________ Perinatal Services Coordinator:______________________Clinic Staff Present: (List all staff present and title) ________________________________________________________________________________________________ITEMSFindings 1 2 3 45Week started prenatal careNumber of OB visits/follows ACOG recommended scheduleClient Orientation is documentedUsing approved assessment forms, initial, trimester and PP assessments completedNutrition AssessmentDiet evaluation used: 24 hr. recall? food frequency questionnaire?Weight every visit; ?plotted on correct grid?Initial (within 4 weeks of initial visit)?Second Trimester?Third Trimester?PostpartumPsychosocial Assessment ?Initial (within 4 weeks of initial visit)?Second Trimester?Third Trimester?PostpartumHealth Education Assessment?Initial (within 4 weeks of initial visit)?Second Trimester?Third Trimester?PostpartumAll documentation includes time in minutesAll entries signed with name and CPSP titleAppropriate use of STT or other materialsAn individual care plan is in place that: Identifies client strengthsAddresses identified OB, health ed, psychosocial, nutrition needs. Care plan updated each trimester and postpartum (dates)ITEMSFindings12 34 5Follow up on risks/issues identified in care planAppropriate referrals documented including but not limited to: WICGenetic ServicesCHDP/Well Child Pediatric CareFamily Planning Dental Appropriate follow up of other referrals Who does case coordination? Dispensed or prescribed vitamin & mineral supplementPhysician supervision documented per protocolDelivery record in chart (use to obtain birth outcome data, follow up if LBW, preterm, elective delivery before 39 wks, c-section)Gender M FBirth weight ____lb. ______oz.Gestational age _______weeks Delivery method: vaginal cesareanFeeding method: Breast Formula CombinationGender ?M ?FBirth weight ____lb. ______oz.Gestational age _______weeks Delivery method: ?vaginal ?cesareanFeeding method: ?Breast ?Formula? CombinationGender ?M ?FBirth weight ____lb. ______oz.Gestational age _______weeks Delivery method: ?vaginal ?cesareanFeeding method: ?Breast ?Formula? CombinationGender ?M ?FBirth weight ____lb. ______oz.Gestational age _______weeks Delivery method: ?vaginal ?cesareanFeeding method: ?Breast ?Formula? CombinationGender ?M ?FBirth weight ____lb. ______oz.Gestational age _______weeks Delivery method: ?vaginal ?cesareanFeeding method: ?Breast ?Formula? CombinationCorrective Action Plan: IssueAction RequiredPerson ResponsibleTarget Date ................
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