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Demograhics and Interim Visit

• Patient ID/Medical Record Number
• ISIS Number
• HRIF Visit Number
• Patient Name
• Visit Date – Including Day of the week, Month, Day and Year
• HRIF ID Number
• Zip Code of Primary Care Giver
• Caregivers contact information
• Caregivers e-mail address
• Visit Status – on time or late
• Who is present at exam with patient
• Patient seen by
• Location of exam
• Interpreter Used?
• Chronologic Age (automatically calculated in months and days)
• Corrected Age (automatically calculated in months and days)
• Routine Child Care
• Living Arrangements
• County of Primary Care
• Insurance: Carrier, Policy Numbers and Comments
• Care Giver’s Concerns since Last Visit with Comment Section
• Medical Equipment Used at Home Since Last Visit
• Medications since Last Visit with Comments
• Hospitalizations since Last Visit Including Reason for Hospitalization and Comment Section
• Procedures since Last Visit with Comments

Visit Data 

• Growth Parameters: Height, Weight and Head Circumference, Classification
• Nutrition and Diet
  Nutrition Type
  Nutritionist’s comments
• Feeding Modes
• Feeding Behavior
• Vitamins
• Sleep Habits
• Elimination Habits
• Physical Exam at Time of Visit
• Neurosensory Assessment
  Does this child have a visual impairment?
  History of ROP
  Eye surgery
  Impairment
  Reason if Visual Impairment is Unknown
  Location of impairments
  Corrective Lens Recommended
  Corrective lens used
• Medical Services Review
  Does this child have a PMD (private medical doctor)?
  Is this child referred for medical services?
  Medical Services Referrals: Services, Dates, Reasons for Referral, Status and Comments
• Hearing Assessment History
  Does this child have a hearing loss, if unknown – why?
• Neurological Assessment
  Was a neurological exam performed?
  Reason if neurological exam was not performed
  Involuntary movements present?
  Summary of neurological assessment
• Oral Motor Function Age Appropriate Responses for the Following
  Feeding and Action Taken
  Swallowing and Action Taken
  Management of Secretions and Action Taken
• Functional Assessment
  Bimanual function
  Right Pincer grasp
  Left Pincer grasp
• Muscle Tone
  Neck
  Trunk
  Right upper limb
  Right lower limb
  Left upper limb
  Left lower limb
• Active Tone
  Vertical Suspension
  Pull to Sit/Head Lag
  Prone Suspended
  Prone Position
• Deep Tendon and Cutaneous Reflexes
  Right upper limb
  Right lower limb
  Left upper limb
  Left lower limb
  Bimetal
  Patellar
  Clonus Left
  Clonus Right
  Primitive reflexes
  Postural reflexes
• Motor Developmental Milestones
  Vocalized
  Eye contact
  Localize a Rattle – if not, action taken
  Track an Object
  Head control
• Motor Activity
  Facial movement
  Tongue fasciculation
  Drooling
• Passive Muscle Tone
  Hip Abductors
  Dorsiflexion
  Scarf sign
  Passive Muscle Trunk
  Popliteal Angle
  Hand movements
  Rigidity
• Craniofacial
  Anterior fontanel
  Sutures
  Skull
  Palate
• Neurosensory Eye Movements
• Cerebral Palsy
  Does the child have cerebral palsy?
  Gross motor function child 18-24 months
  Gross motor function child >24-36 months
• Developmental Assessment
  Was a developmental assessment screen or test performed during this visit?
  Date developmental assessment performed
  Reason if developmental test was not performed.
• Bayley Infant Screener
• Bayley III Hard Copy
  Cognitive Composite
  Language composite
  Gross Motor Scaled Score
  Adaptive behavior composite
  Receptive Language
  Fine motor scaled score
  Social emotional composite
• Bayley III Screener
  Cognitive
  Expressive language
  Receptive language
  Fine motor
  Gross motor
  Motor composite
• Bayley III Comments
• Battelle Developmental Inventory Screening Test, 2nd Edition
  Adaptive domain
  Personal Social Domain
  Motor domain
  Cognitive domain
  Communication
• The Capute Scales
  Language Auditory (CLAMS)
  Cognitive Adaptive (CAT)
  Full Scale Capute
• Other Screens
  Cognitive
  Language Composite
  Fine Motor
  Personal Social
  Receptive Language
  Gross Motor
  Motor Composite
• Adaptive
• OT/PT Comments
• PLS Scores
  Auditory comprehension scale
  Auditory comprehension scaled score
  Expressive communication scaled score
  Total language scaled score age equivalent
  PLS scores total language scaled score
• SLP Comments
• First Steps (KEIS)
• Synagis Candidate
  Chief Complaint
• EMP Score
  EMP score
  EMP Score Pass/Fail
• Autism Screening
Was an autism spectrum screen performed during this visit?
Autism screening tool
Autism screening results
Referred for further autisn assessment?

Referrals and Resources

•  Services
• Receiving Early Intervention Services
  Services through the regional centers prevention program?
  Referred for Special Services
  Infant Development Services and Provider
  Feeding Therapy and Feeding Therapy Provider
  Hearing Services and Hearing services provider
  Behavioral Intervention
  Behavioral Intervention Services
  Nutritional Therapy and Nutritional Therapy Provider
  First Steps (KEIS)
  Vision Series and Vision Services Provider
  Occupational Therapy and occupational therapy provider
  Physical Therapy and Physical Therapy Provider
  Visiting Public Health and Visiting Public Health Provider
  Speech Language communications Therapy and Provider
  Social Work Intervention and Provider
• Resources and Social Concerns
  Care Giver Child disruptions
  Economic and Environmental Concerns
  Community Relationship Concerns
  Parent Child Concerns
• Comment Sections
  Standard Comments Library
• Staff Concerns
• Staff Recommendations

Discharge Information - Auto-populated for patient tracked in NIS™!

• Gestational Age
• Birthweight
• Apgars: 1, 5, 10
• Discharged on Oxygen?
• Home on Monitor?
• Active Diagnoses at the Time of Discharge.
• Cumulative Diagnoses
• Discharge Medications
• Discharge Plan