Maternal Professional Visit Progress Note



MATERNAL Professional Visit Progress NoteMichigan Department of Health and Human ServicesMaternal Infant Health Programs FORMCHECKBOX Blended Visit FORMCHECKBOX Non-billable VisitBeneficiaryMedicaid NumberMedicaid Health Plan FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Location of Visit FORMCHECKBOX Home FORMCHECKBOX Office FORMCHECKBOX Other: FORMTEXT ?????If other, why? FORMTEXT ?????Date of VisitTime InTime Out FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????If approved education tool was discussed, list topic/source FORMTEXT ?????Trimester FORMCHECKBOX 1st FORMCHECKBOX 2nd FORMCHECKBOX 3rd FORMCHECKBOX Unspecified FORMCHECKBOX NAFirst Time MotherProfessional Providing VisitIf RD, is order in place FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX SW FORMCHECKBOX RN FORMCHECKBOX IMHS FORMCHECKBOX RD FORMCHECKBOX Yes FORMCHECKBOX No1st Domain/Risk Addressed (check one) FORMCHECKBOX Abuse/Violence FORMCHECKBOX Family Planning FORMCHECKBOX Pregnancy Health FORMCHECKBOX Transportation FORMCHECKBOX Alcohol FORMCHECKBOX Food/Nutrition FORMCHECKBOX Tobacco FORMCHECKBOX Breastfeeding FORMCHECKBOX Housing FORMCHECKBOX Social Support FORMCHECKBOX Depression/Stress FORMCHECKBOX Medical Considerations FORMCHECKBOX Substance MisuseInterventions provided (list intervention numbers) FORMTEXT ?????Narrative about beneficiary’s reaction to intervention provided FORMTEXT ?????2nd Domain/Risk Addressed (check one) FORMCHECKBOX Abuse/Violence FORMCHECKBOX Family Planning FORMCHECKBOX Pregnancy Health FORMCHECKBOX Transportation FORMCHECKBOX Alcohol FORMCHECKBOX Food/Nutrition FORMCHECKBOX Tobacco FORMCHECKBOX Breastfeeding FORMCHECKBOX Housing FORMCHECKBOX Social Support FORMCHECKBOX Depression/Stress FORMCHECKBOX Medical Considerations FORMCHECKBOX Substance MisuseInterventions provided (list intervention numbers) FORMTEXT ?????Narrative about beneficiary’s reaction to intervention provided FORMTEXT ?????Beneficiary FORMTEXT ?????Other visit information FORMTEXT ?????WIC services being received FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Unknown FORMCHECKBOX NAMIHP action plan completed/reviewed FORMCHECKBOX Yes FORMCHECKBOX NoMedical care provider appointments kept since last visit FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Unknown FORMCHECKBOX NAInfant immunization discussed this visit FORMCHECKBOX Yes FORMCHECKBOX NoMaternal immunization discussed this visit FORMCHECKBOX Yes FORMCHECKBOX NoSafe Sleep addressed this visit FORMCHECKBOX Yes FORMCHECKBOX NoBreastfeeding education provided this visit FORMCHECKBOX Yes FORMCHECKBOX NoEncouraged to attend group childbirth education this visit FORMCHECKBOX Yes FORMCHECKBOX NoPostpartum visit with medical care provider encouraged FORMCHECKBOX Yes FORMCHECKBOX NoBeneficiary feedback and desired plan for next visit FORMTEXT ?????Specific Plan for Next Visit – Staff FORMTEXT ?????Outcome of previous referrals FORMTEXT ?????Beneficiary FORMTEXT ?????New ReferralsBasic NeedsOther FORMCHECKBOX Food FORMCHECKBOX Alcohol FORMCHECKBOX Housing FORMCHECKBOX Child Protective Services (CPS) FORMCHECKBOX Homeless Shelter FORMCHECKBOX Dental FORMCHECKBOX Transportation/Referred to Health Plan FORMCHECKBOX Domestic Violence Services FORMCHECKBOX Transportation/Other FORMCHECKBOX Early On?Breastfeeding FORMCHECKBOX Education FORMCHECKBOX Breastfeeding Support FORMCHECKBOX Employment FORMCHECKBOX Lactation Consultant FORMCHECKBOX Family PlanningInfant Needs FORMCHECKBOX Healthy Michigan Plan FORMCHECKBOX Car Seat FORMCHECKBOX Home Visitation/Support Program FORMCHECKBOX Clothing FORMCHECKBOX Immunization FORMCHECKBOX Crib FORMCHECKBOX Nutritional Counseling (Registered Dietitian)Medical Services FORMCHECKBOX Parenting Education FORMCHECKBOX OB/GYN FORMCHECKBOX Tobacco FORMCHECKBOX Family Practice FORMCHECKBOX Substance MisuseMental Health Services FORMCHECKBOX WIC FORMCHECKBOX Counseling FORMCHECKBOX Other: FORMTEXT ????? FORMCHECKBOX Infant Mental HealthSignature of MIHP ProfessionalCredentials of MIHP ProfessionalDate FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????The Michigan Department of Health and Human Services (MDHHS) does not discriminate against any individual or group because of race, religion, age, national origin, color, height, weight, marital status, genetic information, sex, sexual orientation, gender identity or expression, political beliefs or disability.Beneficiary FORMTEXT ?????If additional Domains are addressed, please use this page.3rd Domain/Risk Addressed (check one) FORMCHECKBOX Abuse/Violence FORMCHECKBOX Family Planning FORMCHECKBOX Pregnancy Health FORMCHECKBOX Transportation FORMCHECKBOX Alcohol FORMCHECKBOX Food/Nutrition FORMCHECKBOX Tobacco FORMCHECKBOX Breastfeeding FORMCHECKBOX Housing FORMCHECKBOX Social Support FORMCHECKBOX Depression/Stress FORMCHECKBOX Medical Considerations FORMCHECKBOX Substance MisuseInterventions provided (list intervention numbers) FORMTEXT ?????Narrative about beneficiary’s reaction to intervention provided FORMTEXT ?????4th Domain/Risk Addressed (check one) FORMCHECKBOX Abuse/Violence FORMCHECKBOX Family Planning FORMCHECKBOX Pregnancy Health FORMCHECKBOX Transportation FORMCHECKBOX Alcohol FORMCHECKBOX Food/Nutrition FORMCHECKBOX Tobacco FORMCHECKBOX Breastfeeding FORMCHECKBOX Housing FORMCHECKBOX Social Support FORMCHECKBOX Depression/Stress FORMCHECKBOX Medical Considerations FORMCHECKBOX Substance MisuseInterventions provided (list intervention numbers) FORMTEXT ?????Narrative about beneficiary’s reaction to intervention provided FORMTEXT ?????MATERNAL PROFESSIONAL VISIT PROGRESS INSTRUCTIONSThese instructions are intended to clarify data fields. If you have additional questions, please contact the MDHHS MIHP Team.One Professional Visit Progress Note must be completed for each professional visit conducted. The Beneficiary Information section, Checkbox section and signature, credentials and date must be completed. Use page four only if more than two POC 2 domains are addressed at one professional visit.Beneficiary Information SectionBlended Visit: Check this box if you are serving two or more beneficiaries with open cases (Risk Identifier completed; Discharge Summary not completed) at this visit. This visit must be billed consistently under only one Medicaid ID. You may not switch back and forth from one beneficiary Medicaid ID to another.Non-billable Visit: Check this box if this professional visit is not intended to be submitted for reimbursement.Beneficiary: Write the beneficiary’s first and last name.Medicaid Number: Write the beneficiary’s Medicaid ID number. If you do not yet have the ID number, leave this field blank. When you obtain the ID number, return to the Professional Visit Progress Note and enter it.Medicaid Health Plan (MHP): Write the name of the beneficiary’s MHP. If beneficiary is not yet enrolled in an MHP, write “FFS” or “straight” or “not in health plan.” It is best practice to check CHAMPS before each visit to see if a beneficiary has enrolled in an MHP since your last visit.Location of Visit: Check the appropriate box for the location of the visit. If the location is not in the office or the home, check the “other” box and write the location of the visit on the line provided. If “other,” the reason why the visit was not held in the office or home is required.Date of Visit: Write the complete date of the visit (month, day, and year). The mm/dd/yyyy format is not required.Time In and Time Out: Write the time the visit began and the time it ended. Each visit must last for a minimum of 30 minutes in order to be billable.If approved education tool was discussed, list topic/source.If an Education packet topic, Text4Baby or approved smartphone application was discussed with he beneficiary/caregiver during the visit write the Education Packet topic or source such as Text4Baby or approved smartphone application in the space provided. Additional information may be provided in the “Other visit information” section.Trimester: Indicate the beneficiary’s trimester of pregnancy at the time of this visit. Per ICD-10 and the American College of Obstetricians and Gynecologists, trimesters are defined as follows:??First trimester:Less than 14 weeks, 0 days??Second trimester:14 weeks, 0 days to less than 28 weeks, 0 days??Third trimester:28 weeks, 0 days until deliveryCheck the “unspecified” box if the trimester in unknown. Check the “NA” box if the beneficiary is not pregnant (e.g., mother has had the baby and this is a postpartum visit, this is an infant visit, mother has lost the baby but you are still completing maternal visits, etc.). You will need trimester information for billing purposes under ICD-10. First Time Mother: Check the “Yes” box if the beneficiary is a first time mother. A first time mother is a woman who has not experienced a live birth, although she may have had a miscarriage, stillbirth or abortion. All first time mothers must be referred to childbirth education classes (CBE). Check the “No” box if the woman has experienced a live birth. If this is a postpartum visit, check the “Yes” box if the infant was the mother's first live birth and do not refer the mother to CBE, as the birth has already occurred.Professional Providing Visit: Check the box corresponding to the professional providing this visit.If RD, is order in place: Check the “Yes” box to demonstrate that a valid physician order is present in the beneficiary’s chart if the RD is conducting the visit.Domain/Risk Addressed SectionDomain/Risk Addressed (check one): Check the appropriate box for the 1st maternal domain/risk addressed at this visit. Check only one domain box in each section. You may choose to leave the unused domain sections blank, draw a line through them, or write “NA.”Interventions Provided: The interventions on each POC 2 risk domain are numbered. Write the number of each specific intervention implemented at this visit on the line provided. Narrative about Beneficiary’s Reaction to Intervention Provided: In the space provided, write a brief description of the beneficiary’s reaction to the numbered interventions specified in the previous field. For sample brief descriptions, see Documenting Reactions to Interventions under “Policy and Operations” on the MIHP web site. If you run out of room, you can continue your narrative on the progress note under “Other visit information,” if needed.Beneficiary: Write the beneficiary’s first and last name. Other visit information: This section is provided to document.??Case management provided for any beneficiary whose Medicaid insurance was not billed for this visit (blended visit). ??Education provided on a topic that is not a POC 2 risk domain or has not been documented in the “Ed packet – Text4baby” section.??ASQ-3 or ASQ: SE-2 was administered.??The reason why a domain was added.??The reason why the risk level was increased or decreased for a particular domain. ??RD professional visit when there is no nutritional POC 2 domain.??Anything else that you want your team members to know.Checkbox SectionThis section consists of a block of questions which must have a response documented in one of the checkboxes on each line.Beneficiary feedback and desired plan for next visit: This section must be completed.Plan for Next Visit Staff: Write a brief description of the plan for the next MIHP visit, identifying the staff’s priority and the beneficiary’s priority. For sample descriptions of plan for next visit, see “Plan for Next Visit” on the MIHP web site. Outcome of previous referrals: Write a brief description of the outcome of referrals made at previous visits. For example, “Beneficiary followed through with call to CMH and has an appt. on such and such a date;” “Beneficiary decided not to access this resource;” “Beneficiary obtained food from the food bank,” etc. This documentation must be provided within 3 professional visits from the date of the referral. This is not a required field on every progress note. New referrals: Check all boxes that apply for referrals made this visit. If you check the “Other” box, use the space provided to specify where you referred the beneficiary.This is not a required section on every progress note.Signature and credentials of MIHP Professional: MIHP professional must legibly sign their first and last name followed by professional credentials.Signature Date: The date required here is the date that the progress note was completed and signed. This date may be different from the “Date of Visit” documented on page one of the progress note. ................
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