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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
    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
    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
    Clonus Left
    Clonus Right
    Primitive reflexes
    Postural reflexes
  • Motor Developmental Milestones
    Eye contact
    Localize a Rattle – if not, action taken
    Track an Object
    Head control
  • Motor Activity
    Facial movement
    Tongue fasciculation
  • Passive Muscle Tone
    Hip Abductors
    Scarf sign
    Passive Muscle Trunk
    Popliteal Angle
    Hand movements
  • Craniofacial
    Anterior fontanel
  • 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
    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
  • The Capute Scales
    Language Auditory (CLAMS)
    Cognitive Adaptive (CAT)
    Full Scale Capute
  • Other Screens
    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