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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