HEALTHY STARTFAMILY SPIRIT INFANTCHILD MEDICAL CARE LOG HSID 

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1 HEALTHY SOILS ALL OVER THE COUNTRY [SOME SOILS
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Healthy Start/Family Spirit Infant/Child Medical Care Log

HSID:       Date Medical Chart Review Started:       Date of update:       Staff:      

Infant/Child First name:       Infant/Child Last Name:      

Current Address:       Phone:       No Phone

Race: AI/AN White African Amer. Asian/PI Other Hispanic: No Yes

Date of Birth:      

Status

Definition of medical home: “MCHB uses the AAP definition of medical home. The definition establishes that the medical care of infants, children, and adolescents should be accessible, continuous, comprehensive, family-centered, coordinated, and compassionate. It should be delivered or directed by well-trained physicians who are able to manage or facilitate essentially all aspects of pediatric care. The physician should be known to the child and family and should be able to develop a relationship of mutual responsibility and trust.”

Update Date:

Health Insurance Status

Medical Home Status


Medicaid MI-Child Private None

Yes No


Medicaid MI-Child Private None

Yes No


Medicaid MI-Child Private None

Yes No


Medicaid MI-Child Private None

Yes No


Medicaid MI-Child Private None

Yes No


Medicaid MI-Child Private None

Yes No


Medicaid MI-Child Private None

Yes No


Medicaid MI-Child Private None

Yes No


Medicaid MI-Child Private None

Yes No


Medicaid MI-Child Private None

Yes No


Medicaid MI-Child Private None

Yes No


Medicaid MI-Child Private None

Yes No


Medicaid MI-Child Private None

Yes No


Medicaid MI-Child Private None

Yes No









Meets CSHCN criteria? Yes       No



Recommended Infant/Child Well-child Visit Schedule

*Please exclude children with special needs or who are at or in high risk medical situations. An alternative visit schedule may be needed


  1. Based on the birthdate of the child, the system will autopopulate the target dates for well-child visits.

  2. Document which visits have already been completed for the infant/child and check “Completed box”


Target Date

Check (x) if Completed

Date Visit Completed

Concerns Indentified at Visit

Infancy

Newborn/in hospital

 




2-4 Days post discharge

 




By 1 Month

 




2 Months

 




4 Months

 




6 Months

 




9 Months

 




12 Months

 




15 Months

 




Early Childhood

18 Months

 




24 Months

 




3 Years

 




4 Years

 




5 Years

 





Total Visits:

 






Total Possible Visits: (calculated by system) Total Visits Completed: (calculated by system)





















Log chart for Illness/Emergency Room and Medical (other than well-child) Visits


(You may check more than one Type of Visit)


Date of Visit

Type of Visit

Reason:

      

  Emergency Room

Child Injury or Ingestion (All visit types)

Medical Care Visit (All Causes)

Hospital Admissions (All Causes)

     

      

  Emergency Room

Child Injury or Ingestion (All visit types)

Medical Care Visit (All Causes)

Hospital Admissions (All Causes)

     

      

  Emergency Room

Child Injury or Ingestion (All visit types)

Medical Care Visit (All Causes)

Hospital Admissions (All Causes)

     

      

  Emergency Room

Child Injury or Ingestion (All visit types)

Medical Care Visit (All Causes)

Hospital Admissions (All Causes)

     

      

  Emergency Room

Child Injury or Ingestion (All visit types)

Medical Care Visit (All Causes)

Hospital Admissions (All Causes)

     

     

Emergency Room

Child Injury or Ingestion (All visit types)

Medical Care Visit (All Causes)

Hospital Admissions (All Causes)

     

     

Emergency Room

Child Injury or Ingestion (All visit types)

Medical Care Visit (All Causes)

Hospital Admissions (All Causes)

     

     

Emergency Room

Child Injury or Ingestion (All visit types)

Medical Care Visit (All Causes)

Hospital Admissions (All Causes)

     

     

Emergency Room

Child Injury or Ingestion (All visit types)

Medical Care Visit (All Causes)

Hospital Admissions (All Causes)

     

      

  Emergency Room

Child Injury or Ingestion (All visit types)

Medical Care Visit (All Causes)

Hospital Admissions (All Causes)

     



5/19/2015 version


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Tags: healthy start/family, spirit, medical, infantchild, startfamily, healthy