pediatric review of systems phrases - tswf-mhs.com€¦ · web viewhighlighted text indicates a...

MHS GenesisT2 Pediatric AutoText Phrases

Instructions for use:To create new AutoText Phrases:

1. From the Home screen, click Messages within the Inbox Summary panel on the left side of the screen.

2. Click the Communicate button.3. On the Message toolbar, click the Manage AutoText button. 4. Click the Add New Phrase button . 5. Copy and Paste the phrase Abbreviation into the Abbreviation field.6. Copy and Paste the phrase text into the text field.7. Highlighted text indicates a drop-down list of selections. Select the entire highlighted

area and click the Create Drop List button. 8. Each item of varying color should be converted to a drop-down item by copying the

item, clicking the Add List Item button, then pasting the new item.9. Click the Create button when all drop-down items have been created. All highlighting

will disappear after the items are converted to a list.10. When finished creating all drop downs, review the AutoText phrase, then click the

Save button.

ContentsPEDIATRIC PHYSICAL EXAM PHRASES..............................................................2PEDIATRIC REVIEW OF SYSTEMS PHRASES....................................................15PEDIATRIC SCREENING PHRASES...................................................................19PEDIATRIC WELL CHILD PHRASES..................................................................25

11.

MILITARY HEALTH SYSTEM

T2 Pediatric STG AutoText

PEDIATRIC REVIEW OF SYSTEMS PHRASESAbbreviation: 2tpeds-ros-adhdDescription:

ADHD Review of systems (ROS)Systemic: No recent involuntary weight loss (or Unintentional Weight Loss).Head: No headache.Cardiovascular: No chest pain or discomfort and no palpitations.Gastrointestinal: Appetite not decreased. No abdominal pain.Neurological: No fainting and no tics.Psychological: No emotional lability, no sleep disturbances, and no initial insomnia.

Abbreviation: 2tpeds-ros-asthmaDescription:

Asthma review of systems (ROS) Otolaryngeal: No nasal discharge and No nasal passage blockage (stuffiness). Pulmonary: Cough does Not occur during the day or during the night. Not coughing on exertion or during exercise and there is no wheezing with a cold. No wheezing. No dyspnea.

Abbreviation: 2tpeds-ros-complete-0-24monthsDescription:

Review of systems (ROS)Systemic: Not feeling tired (fatigue). No chills, no night sweats, and no failure to gain weight as expected.Head: No sinus pain and normal head shape.Neck: No neck pain and no swollen glands in the neck.Eyes: No vision problems, eyes not crossed, eyes not turned out, and no eye pain. No discharge from the eyes, no photophobia, and no red eyes.Otolaryngeal: No hearing loss, no earache, no epistaxis, no snoring, and no sore throat.Breasts: No breast lump and no pain in breast.Cardiovascular: No palpitations.Pulmonary: No dyspnea and no rapid breathing.Gastrointestinal: Not a picky eater and no heartburn. No nausea, no jaundice, bowel movement frequency has not recently changed, and no hematochezia. No constipation.Genitourinary: No hematuria, no changes in urinary habits, no change in urinary frequency, and no feelings of urinary urgency. No urinary loss of control, no dysuria, no pain in the flank, and no testicular lump. No abnormal urethral discharge.Endocrine: No polydipsia, no temperature intolerance, and denied concerns about sexual development. No hair symptoms.Hematologic: No easy bleeding and no tendency for easy bruising.Musculoskeletal: No back pain and no myalgias. No localized joint pain, no localized joint swelling, and no limb swelling.

of 41


Neurological: No dizziness, no lightheadedness, no decrease in concentrating ability, no convulsions, and no staring spells. No motor disturbances, no limb weakness, and no tics. No gait abnormality. No sensory disturbances.Psychological: No anxiety, no emotional lability, no depression, not acting fussy, and no sleep apnea. No loss of interest in activities, no loss of interest in friends and family, no decreased functioning ability, and good school performance. No violent behavior and no hyperactive behavior. Not crying for no reason.Skin: No dry skin, no pruritus, no pallor, and no cyanosis. No skin lesions.

Abbreviation: 2tpeds-ros-complete-2-6yearDescription:

Review of systems Systemic: Not feeling tired (fatigue). No chills and no night sweats.Head: No sinus pain and normal head shape.Neck: No neck pain and no swollen glands in the neck.Eyes: Eyes not crossed, eyes not turned out, and no eye pain. No photophobia and no red eyes.Otolaryngeal: No epistaxis.Breasts: No breast lump and no pain in breast.Cardiovascular: No palpitations.Pulmonary: No rapid breathing.Gastrointestinal: Not a picky eater and no heartburn. No nausea, no jaundice, and no hematochezia. No constipation.Genitourinary: No hematuria, no change in urinary frequency, and no feelings of urinary urgency. No urinary loss of control, no dysuria, and no pain in the flank. No vaginal discharge and no abnormal urethral discharge.Endocrine: No temperature intolerance and denied concerns about sexual development. No hair symptoms.Hematologic: No easy bleeding and no tendency for easy bruising.Musculoskeletal: No back pain and no myalgias. No localized joint pain, no localized joint swelling, and no limb swelling.Neurological: No dizziness, no lightheadedness, no decrease in concentrating ability, no convulsions, and no staring spells. No motor disturbances, no limb weakness, and no tics. No gait abnormality. No sensory disturbances.Psychological: No anxiety, no emotional lability, no depression, not acting fussy, and no sleep apnea. No loss of interest in activities, no loss of interest in friends and family, no decreased functioning ability, good school performance, and not thinking about suicide. No homicidal thoughts, no violent behavior, and no hyperactive behavior. Not crying for no reason.Skin: No dry skin, no pruritus, no pallor, and no cyanosis. No skin lesions.

Abbreviation: 2tpeds-ros-complete-female-7-18yearDescription:

Review of systems (female)Systemic: Not feeling tired (fatigue). No chills and no night sweats.Head: No sinus pain and normal head shape.Neck: No neck pain and no swollen glands in the neck.Eyes: No vision problems, eyes not crossed, eyes not turned out, and no eye pain. No photophobia and no redeyes.Otolaryngeal: No hearing loss and no epistaxis.

of 41


Breasts: No breast lump and no pain in breast.Cardiovascular: No palpitations.Pulmonary: No rapid breathing.Gastrointestinal: Not a picky eater and no heartburn. No nausea, no jaundice, and no hematochezia. No constipation.Genitourinary: No hematuria, no change in urinary frequency, and no feelings of urinary urgency. No urinary loss of control, no dysuria, no pain in the flank, periods are regular, regular length of periods, and no menorrhagia. No dysmenorrhea and no bleeding between periods. No vaginal discharge and no abnormal urethral discharge.Endocrine: No temperature intolerance and denied concerns about sexual development. No hair symptoms and no unusual body odor.Hematologic: No easy bleeding and no tendency for easy bruising.Musculoskeletal: No back pain and no myalgias. No localized joint pain, no localized joint swelling, and no limb swelling.Neurological: No lightheadedness, no decrease in concentrating ability, no convulsions, and no staring spells. No motor disturbances, no limb weakness, and no tics. No gait abnormality. No sensory disturbances.Psychological: No anxiety, no high irritability, no emotional lability, no depression, and no sleep apnea. No loss of interest in activities, no loss of interest in friends and family, no decreased functioning ability, good school performance, and not thinking about suicide. No homicidal thoughts, no violent behavior, and not feeling that one is obese when normal or thin. No hyperactive behavior.Skin: No dry skin, no pruritus, no pallor, and no cyanosis. No skin lesions.

Abbreviation: 2tpeds-ros-complete-male-7-18yearDescription:

Review of systems (male)Systemic: Not feeling tired (fatigue). No chills and no night sweats.Head: No sinus pain and normal head shape.Neck: No neck pain and no swollen glands in the neck.Eyes: No vision problems, eyes not crossed, eyes not turned out, and no eye pain. No photophobia and no red eyes.Otolaryngeal: No hearing loss and no epistaxis.Breasts: No breast lump and no pain in breast.Cardiovascular: No palpitations.Pulmonary: No rapid breathing.Gastrointestinal: Not a picky eater and no heartburn. No nausea, no jaundice, and no hematochezia. No constipation.Genitourinary: No hematuria, no change in urinary frequency, and no feelings of urinary urgency. No urinary loss of control, no dysuria, no pain in the flank, and no testicular lump. No abnormal urethral discharge.Endocrine: No temperature intolerance and denied concerns about sexual development. No hair symptoms and no unusual body odor.Hematologic: No easy bleeding and no tendency for easy bruising.Musculoskeletal: No back pain and no myalgias. No localized joint pain, no localized joint swelling, and no limb swelling.Neurological: No lightheadedness, no decrease in concentrating ability, no convulsions, and no staring spells. No motor disturbances, no limb weakness, and no tics. No gait abnormality. No sensory disturbances.Psychological: No anxiety, no high irritability, no emotional lability, no depression, and no sleep apnea. No loss of interest in activities, no loss of interest in friends and family, no decreased functioning ability, good school performance, and not thinking about suicide. No

of 41


homicidal thoughts, no violent behavior, and not feeling that one is obese when normal or thin. No hyperactive behavior.Skin: No dry skin, no pruritus, no pallor, and no cyanosis. No skin lesions.

Abbreviation: 2tpeds-ros-newpatientDescription:

Review of systems (ROS) Systemic: No recent weight change. Otolaryngeal: No snoring. Cardiovascular: No chest pain or discomfort. Pulmonary: No dyspnea. Gastrointestinal: Bowel movement frequency has not recently changed. Genitourinary: No changes in urinary habits. Endocrine: No polydipsia. Musculoskeletal: No limb pain. Neurological: No fainting. Psychological: No sleep disturbances.

Abbreviation: 2tpeds-ros-quickDescription:

Review of systems (ROS) Systemic: No fever. Head: No headache. Eyes: No discharge from the eyes. Otolaryngeal: No earache, not pulling at the ear(s), no sore throat, no nasal discharge, and no nasal passage blockage (stuffiness). Pulmonary: No cough and no wheezing. Gastrointestinal: No vomiting, no diarrhea, and appetite not decreased. No abdominal pain. Skin: No rash.

Abbreviation: 2tpeds-ros-sportsparticipationDescription:

Sports participation review of systems (ROS) Systemic: Not feeling overweight and not feeling underweight. Not feeling tired (no fatigue). Cardiovascular: No chest pain during exertion. Pulmonary: No dyspnea during exertion. No cough and no wheezing. Musculoskeletal: No limb pain. Neurological: No numbness of the limbs. No dizziness. No fainting with exercise. Skin: No rash.

Abbreviation: 2tpeds-ros-viralDescription:

Viral review of systems (ROS) Systemic: No fever.

of 41


Otolaryngeal: Not pulling at the ear(s), no nasal discharge, and no nasal passage blockage (stuffiness).Pulmonary: No cough and no wheezing.Gastrointestinal: Appetite not decreased. No vomiting, no abdominal pain, and no diarrhea.Skin: No rash.

PEDIATRIC SCREENING PHRASES Abbreviation: 2tpeds-screen-annualquestionsDescription:

Annual Questions:Preferred language (written or spoken): English Other:Preferred method of Learning? Verbal Written Other:Learning disability, language barrier, hearing/vision deficit? No Yes(SILS) How often does parent need to have someone help when reading instructions, pamphlets, or other written material from doctor or pharmacy? Never Rarely Sometimes Often Always//Instructions// If "often or always" use 2tpeds-screen-healthliteracyInstructions for patient understood by caregiver/parent: Yes NoDo you have any cultural or religious beliefs that may affect your care? No YesAre you enrolled in EMFP? No YesContact Preference:_PCM:_

Abbreviation: 2tpeds-screen-healthliteracyDescription:

Health Literacy: (CDS http://tswf-mhs.com/stg/cds/421 REALM-SF needed only when SILS question in annual questions is “often” or “always”)Administered health literacy deficit assessment.

REALM-SF Reading Assessment: Number of words pronounced correctly: [_] (Menopause, Antibiotics, Exercise, Jaundice, Rectal, Anemia, Behavior)

Other Assessment tool: _

Health literacy response care plan:[_] Referral to special needs care coordinator[_] Other: _

Abbreviation: 2tpeds-screen-c-ssrsDescription:

C-SSRS ( CDS http://tswf-mhs.com/stg/cds/181 )In the past month have you?1: Have you wished you were dead or wished you could go to sleep and not wake up? No **Yes**

of 41

http://tswf-mhs.com/stg/cds/181


2: Have you had any actual thoughts of killing yourself? No (skip to question #6) **Yes**3: Have you been thinking about how you might do this? No **Yes** 4: Have you had these thoughts and had some intention of acting on them? No **Yes** 5: Have you started to work out or worked out the details of how to kill yourself? Do you intend to carry out this plan? No **Yes**In your lifetime have you?6a: Have you ever done anything, started to do anything, or prepared to do anything to end your life? No **Yes**6b: Within the last three months? No **Yes** C-SSRS Summary:The patient's suicide risk level was evaluated with the Columbia Suicide Severity Rating Scale. No suicide risk items were endorsed Minimal Suicide Risk Level according to patient responses. **Moderate** Suicide Risk Level according to patient responses. Actions taken:_ **High** Suicide Risk Level according to patient responses. Actions taken:_

Abbreviation: 2tpeds-screen-crafftDescription:

CRAFFT Screening (CDS https://www.tswf-mhs.com/stg/cds/24)C:_R:_A:_F:_F:_T:_ CRAFFT Score: [ _ ]The score does not indicate the presence of problems with alcohol/drug use. **The scores indicates that the patient may be experiencing problems related to alcohol/drug use.**

Abbreviation: 2tpeds-screen-domesticviolenceDescription:

Has patient or parent ever been forced / pressured to engage in any sexual activity or touched in a way that made you feel uncomfortable? No **Yes** Declined to answer. Notify providerHas patient or parent ever been hit, kicked, slapped, pushed or shoved by your partner or someone important to you? No **Yes** Declined to answer. Notify provider

Abbreviation: 2tpeds-screen-flaccDescription:

FLACC pain scale: FACE: 0 No particular expression or smile. 1 Occasional grimace or frown, withdrawn, disinterested. 2 Frequent to constant quivering chin, clenched jaw.LEGS: 0 Normal position or relaxed. 1 Uneasy, restless, tense. 2 Kicking, or legs drawn up.ACTIVITY: 0 Lying quietly, normal position moves easily. 1 Squirming, shifting back and forth, tense. 2 Arched, rigid or jerking.CRY: 0 No cry, (awake or asleep). 1 Moans or whimpers; occasional complaint. 2 Crying steadily, screams or sobs, frequent complaints.

of 41


CONSOLABILITY: 0 Content, relaxed. 1 Reassured by occasional touching hugging or being talked to, distractible. 2 Difficulty to console or comfort.FLACC total score: 0 1 2 3 4 5 6 7 8 9 10

Abbreviation: 2tpeds-screen-generalDescription:

2tpeds-screen-flaccPain(Wong-Baker Faces): 0 1 2 3 4 5 6 7 8 9 10 /10

Source of information: Patient Mother Father Other: _ Has patient received any type of care since their last visit with this clinic? No Yes Is the patient or parent currently in a situation where they are being verbally or physically hurt, threatened, or made to feel afraid? No **Yes** //Instructions// If Yes use 2tpeds-screen-domesticviolence

2tpeds-screen-annualquestions2tpeds-screen-travelhistory2tpeds-screen-zika2tpeds-screen-pre-travel-counseling2tpeds-screen-healthliteracy Nutrition: No change Updated in patient’s chart: Social: Nutrition: Diet

ROS:2tpeds-ros-quick2tpeds-ros-viral2tpeds-ros-asthma2tpeds-ros-newpatient

Abbreviation: 2tpeds-screen-newbornquestionnaireDescription:

Newborn Questionnaire:Birth History: Date of Discharge:_Time of Birth:_Hospital Name:_Discharge weight:_Estimated Gestational Age:_Method of Delivery: vaginal c-section other:_Complications at birth: none Prenatal history: uncomplicatedNewborn Screening: normal **abnormal** Vision screening: pass **fail**Hearing screening: pass **fail** Instructions: _ //Instructions//Go to Diagnoses and Problems, click “Add”, type in “birth” for Condition and then search, choose “Birth” snowmed code 8587019 then _ in the “Display As” field change the name to “Birth HX”, click “OK”, then paste answers to questions above into the comments box.

of 41


Nutrition: Breast feeding: [_] of times per day; for [_] minutes per breast; [_] of hours between feedings.Bottle feeding: [_] of oz per feeding; Fortified formula; type [_]; and [_] ozs/day.

How many wet diapers in last 24 hours:_How many stools in last 24 hours:_What was the color of the last stool:_

Informed the Parent: To feed baby Q2hrs around the clock; In a 24hr period there should be 6+ Wet diapers and 3+ Stools; Lactation Consultant 247-3249 or visit peds; Nurse Advice Line 1-800-Tricare, Option 1; Bring Discharge Paperwork (including Vaccine Hx) to NB Appt.

Abbreviation: 2tpeds-screen-phq2Description:

2 Question Depression Screening:Over the last 2 weeks, how often have you been bothered by any of the following problems? 0-not at all 1-several days 2-more than half the days 3-nearly every day 1) Little Interest or pleasure in doing things.0-not at all 1-several days 2-more than half the days 3-nearly every day 2) Feeling down, depressed, irritable or hopeless.2 Question Depression Screen score: _ Interpretation: Negative **Positive** - Score of 2 or higher on either question //Instructions// if positive, complete 2tpeds-screen-phq9a and alert provider.

Abbreviation: 2tpeds-screen-phq9a Description:

PHQ-9A (CDS http://tswf-mhs.com/stg/cds/181)Over the last 2 weeks, how often have you been bothered by any of the following problems? 0-not at all 1-several days 2-more than half the days 3-nearly every day 1) Feeling down, depressed, irritable, or hopeless 0-not at all 1-several days 2-more than half the days 3-nearly every day 2) Little Interest or pleasure in doing things 0-not at all 1-several days 2-more than half the days 3-nearly every day 3) Trouble falling asleep, staying asleep, or sleeping too much 0-not at all 1-several days 2-more than half the days 3-nearly every day 4) Poor appetite, weight loss or overeating 0-not at all 1-several days 2-more than half the days 3-nearly every day 5) Feeling tired or having little energy 0-not at all 1-several days 2-more than half the days 3-nearly every day 6) Feeling bad about yourself or that you are a failure or have let yourself or your family down 0-not at all 1-several days 2-more than half the days 3-nearly every day 7) Trouble concentrating on things, such as school work, reading or watching television 0-not at all 1-several days 2-more than half the days 3-nearly every day 8) Moving or speaking so slowly that other people could have noticed. Or the opposite - being so fidgety or restless that you have been moving around a lot more than usual0-not at all 1-several days 2-more than half the days 3-nearly every day 9) Thoughts that you would be better off dead, or of hurting yourself in some way

of 41


10) In the PAST YEAR have you felt depressed or sad most days, even if you felt okay sometimes? No **Yes**11) If you are experiencing any of the problems on this form, how difficult have these problems made it for you to do your work, take care of things at home or get along with other people? Not at all Somewhat **Very** **Extremely** 12) Has there been a time in the past month when you have had serious thoughts about ending your life? No **Yes** 13) Have you EVER, in your WHOLE LIFE, tried to kill yourself or made a suicide attempt? No **Yes**

PHQ-9A score: [ _ ]

Abbreviation: 2tpeds-screen-pre-travel-counselingDescription:

Pre-travel counseling: Patient is traveling to _ on _.Discussed the following health/safety risks and recommended precautions.- Current CDC travel advisories- Following specific disease(s); _- Immunizations- Food and drink safety- Bug bite prevention- Caution around animals- Climate and outdoor precautions- Transportation and personal safety- Avoiding bodily fluid- Importance of knowing how to get medical care while traveling:(CDS CDC Pre-Travel Information: https://www.cdc.gov/travel/page/traveler-information-center CDC Travel Health Notices: https://www.cdc.gov/travel/notices)

Abbreviation: 2tpeds-screen-pscDescription:All

PSC: Pediatric Symptoms Checklist (CDS http://tswf-mhs.com/stg/cds/179)[_] PSC-Y Administered: [_] PSC Administered: Total Score:[_]Attention Subscale Score:[_]Externalizing Subscale Score:[_]Internalizing Subscale Score:[_]

Abbreviation: 2tpeds-screen-scaredDescription:

SCARED: Screen for Anxiety Related Disorders (CDS http://tswf-mhs.com/stg/cds/184)Total Score:_ Panic Score:_ General Anxiety Score:_

of 41


Separation Anxiety Score:_ Social Anxiety Score:_ Significant School Avoidance Score:_

Abbreviation: 2tpeds-screen-travelhistoryDescription:

Travel history (CDS http://wwwnc.cdc.gov/travel/diseases/ http://wwwnc.cdc.gov/travel/notices/ http://wwwnc.cdc.gov/travel/page/in-clinic-quick-links/ http://wwwnc.cdc.gov/travel/page/travel-medicine-references/ )Travel from _on _ mon/day/yr_ to _ Return on_Travel from _on _ mon/day/yr_ to _ Return on_Did the patient experience illness during the trip? No **Yes** (details):

Abbreviation: 2tfpma-screen-tobaccocessationDescription:

Tobacco Cessation Counseling: (3-10 min): discussed impact of tobacco use on health, benefits of tobacco cessation, support resources to include 1800-QUIT-NOW, web-based resources, MTF Tobacco Cessation Program, medication options and quit strategies w/pt CPT code 99406 (>10min): discussed impact of tobacco use on health, benefits of tobacco cessation, support resources to include 1800-QUIT-NOW, web-based resources, MTF Tobacco Cessation Program, medication options and quit strategies w/pt CPT code 99407

Abbreviation: 2tpeds-screen-vanderbiltDescription:

Vanderbilt Rating Scale: (CDS http://www.pampapediatrics.com/client_images/File/vanderbilt-forms.pdf )

PARENT A:[ _ / 9 ] Inattentive [ _ / 9 ] Hyperactive/Impulsive [ _ / 8 ] ODD [ _ /14 ] Conduct Disorder [ _ / 7 ] Anxiety/Depression PARENT B:[ _ / 9 ] Inattentive [ _ / 9 ] Hyperactive/Impulsive [ _ / 8 ] ODD [ _ /14 ] Conduct Disorder [ _ / 7 ] Anxiety/Depression TEACHER A: [ _ / 9 ] Inattentive [ _ / 9 ] Hyperactive [ _ / 10 ] ODD/CD [ _ / 7 ] Anxiety/Depression TEACHER B: [ _ / 9 ] Inattentive [ _ / 9 ] Hyperactive [ _ / 10 ] ODD/CD [ _ / 7 ] Anxiety/Depression

Abbreviation: 2tpeds-screen-zikaDescription:

Zika Risk Assessment: (CDS https://wwwnc.cdc.gov/travel/page/world-map-areas-with-zika https://www.cdc.gov/zika/prevention/transmission-methods.html) 1. Have you or your sexual partner traveled to or live in a Zika affected area in the past 6 months or are any of you planning to in the future? No **Yes** 2. Are you pregnant or do you plan to conceive in the next 6 months? No **Yes**

of 41


PEDIATRIC WELL CHILD PHRASES Abbreviation: 2tpeds-well-12month-screenDescription: Use as base duplication template for creating well child phrases from 3-5 days through 30 month.

Visit for 12 month old well child (CDS http://tswf-mhs.com/stg/cds/197)2tpeds-screen-flacc

Vision Spot Screener:R SE _/ DS _/ DC _/ Axis @ _ DEGL SE _/ DS _/ DC _/ Axis @ _ DEG Rec. All in range Anisometropia Astigmatism Myopia Hyperopia Anisocoria Gaze Vertical Gaze Nasal Gaze Temporal Gaze Asymmetry , _ Anisometropia Astigmatism Myopia Hyperopia Anisocoria Gaze Vertical Gaze Nasal Gaze Temporal Gaze Asymmetry , _ Anisometropia Astigmatism Myopia Hyperopia Anisocoria Gaze Vertical Gaze Nasal Gaze Temporal Gaze Asymmetry , _ Anisometropia Astigmatism Myopia Hyperopia Anisocoria Gaze Vertical Gaze Nasal Gaze Temporal Gaze Asymmetry

Source of information: mother father other:_Has patient received any type of care since their last visit with this clinic? No YesIs the patient or parent currently in a situation where they are being verbally or physically hurt, threatened, or made to feel afraid? No Yes Declined to answer //Instruction// if Yes perform follow up questions using 2tfpma-screen-domesticviolence and notify provider //Instruction// if Declined to answer, notify providerImmunizations: Reviewed and current as of: _ Reviewed and recommended: _ Immunizations refused ( CDS https://www.cdc.gov/vaccines/schedules/hcp/imz/child-adolescent.html http://www.tswf-mhs.com/files/EHR/AIM%20Forms/AIM%20Form%20Documents/Pediatrics/Refusal-to-vaccinate-caregiver-consent.pdf )

Lead Screening: Does your child live in or visit a home or child care facility with an identified lead hazard or a home built before 1960 that is in poor repair or was renovated in the past 6 months? No **Yes** details:_

Tuberculosis Screening: Has a family member or contact had tuberculosis? No **Yes** details:_Has a family member had a positive tuberculin skin test? No **Yes** details:_Was your child born in a high-risk country? No **Yes** details:_Has your child traveled to a high risk country for more than one week? No **Yes** details:_

2tpeds-screen-annualquestions2tpeds-screen-travelhistory2tpeds-screen-zika2tpeds-screen-pretravelcounseling2tpeds-screen-healthliteracy Nutrition: no change updated in patient’s chart: Social: Nutrition: Diet

ROS:

of 41

http://www.tswf-mhs.com/files/EHR/AIM%20Forms/AIM%20Form%20Documents/Pediatrics/Refusal-to-vaccinate-caregiver-consent.pdf

http://www.tswf-mhs.com/files/EHR/AIM%20Forms/AIM%20Form%20Documents/Pediatrics/Refusal-to-vaccinate-caregiver-consent.pdf

https://www.cdc.gov/vaccines/schedules/hcp/imz/child-adolescent.html



2tpeds-ros-quick2tpeds-ros-viral2tpeds-ros-asthma2tpeds-ros-complete-0-24months

ASQ Months:12 Communication:[_] Gross Motor:[_] Fine Motor:[_] Problem Solving:[_] Personal/Social:[_]Milestones:SOCIAL – EMOTIONAL [Y] Waves bye-bye [Y] Tries to do what you do [Y] Cries when you leave [Y] Plays peekaboo [Y] Hands you a book to readCOMMUNICATIVE [Y] Speaks 1-2 words [Y] Babbles [Y] Tries to make the same sounds you do [Y] Looks at things you are looking atCOGNITIVE [Y] Follows simple directionsPHYSICAL DEVELOPMENT [Y] Bangs toys together [Y] Pulls to stand [Y] Stands alone [Y] Drinks from cup

Abbreviation: 2tpeds-well-3-5day-screenDescription:

Visit for 3-5 day well child (CDS http://tswf-mhs.com/stg/cds/190)2tpeds-screen-flacc Source of information: mother father other:_Has patient received any type of care since their last visit with this clinic? No YesIs the patient or parent currently in a situation where they are being verbally or physically hurt, threatened, or made to feel afraid? No Yes Declined to answer //Instruction// if Yes perform follow up questions using 2tfpma-screen-domesticviolence and notify provider //Instruction// if Declined to answer, notify provider2tpeds-screen-annualquestions2tpeds-screen-travelhistory2tpeds-screen-zika2tpeds-screen-pretravelcounseling2tpeds-screen-healthliteracy Nutrition: Breast feeding: [_] of times per day; for [_] minutes per breast; [_] of hours between feedings.Bottle feeding: [_] of oz per feeding; Fortified formula; type [_]; and [_] ozs/day. Elimination: No Yes concerns about bowel movements or constipation. [_] of wet diapers per day.Sleep Habits: No Yes sleep disturbance.

ROS:2tpeds-ros-quick2tpeds-ros-viral2tpeds-ros-asthma2tpeds-ros-complete-0-24months

of 41


Milestones:SOCIAL - EMOTIONAL: [ Y ] Eats wellCOGNITIVE: [ Y ] Follows your faceCOMMUNICATIVE: [ Y ] Turns and calms to your voice PHYSICAL DEVELOPMENT: [ Y ] Can suck, swallow, and breathe easy

Abbreviation: 2tpeds-well-2week-screenDescription:

Visit for 2 week old well child (CDS http://tswf-mhs.com/stg/cds/191)2tpeds-screen-flacc Source of information: mother father other:_Has patient received any type of care since their last visit with this clinic? No YesIs the patient or parent currently in a situation where they are being verbally or physically hurt, threatened, or made to feel afraid? No Yes Declined to answer //Instruction// if Yes perform follow up questions using 2tfpma-screen-domesticviolence and notify provider //Instruction// if Declined to answer, notify provider 2tpeds-screen-annualquestions2tpeds-screen-travelhistory2tpeds-screen-zika2tpeds-screen-pretravelcounseling2tpeds-screen-healthliteracy Nutrition: no change updated in patient’s chart: Social: Nutrition: Diet


Milestones:SOCIAL - EMOTIONAL: [Y] If upset, able to calmCOGNITIVE: [Y] Has started to smileCOMMUNICATIVE: [Y] Regards voice of parents [Y] Follows parent with eyesPHYSICAL DEVELOPMENT: [Y] Able to lift head when on tummy

Abbreviation: 2tpeds-well-1month-screen Description:

Visit for 1 month old well child (CDS http://tswf-mhs.com/stg/cds/192)2tpeds-screen-flacc Source of information: mother father other:_Has patient received any type of care since their last visit with this clinic? No YesIs the patient or parent currently in a situation where they are being verbally or physically hurt, threatened, or made to feel afraid? No Yes Declined to answer //Instruction// if Yes

of 41


perform follow up questions using 2tfpma-screen-domesticviolence and notify provider //Instruction// if Declined to answer, notify providerEdinburgh Postnatal Depression Screen Completed and appropriate action taken as per clinic protocol CDS http://www.fresno.ucsf.edu/pediatrics/downloads/edinburghscale.pdf


2tpeds-screen-annualquestions2tpeds-screen-travelhistory2tpeds-screen-zika2tpeds-screen-pretravelcounseling2tpeds-screen-healthliteracy Nutrition: no change updated in patient’s chart: Social: Nutrition: DietElimination: No Yes concerns about bowel movements or constipation. [_] of wet diapers per day.Sleep Habits: No Yes sleep disturbance.


Milestones:SOCIAL - EMOTIONAL: [Y] If upset, able to calmCOGNITIVE: [Y] Has started to smileCOMMUNICATIVE: [Y] Regards voice of parents [Y] Follows parent with eyesPHYSICAL DEVELOPMENT: [Y] Able to lift head when on tummy

Abbreviation: 2tpeds-well-2month-screenDescription:

Visit for 2 month old well child (CDS http://tswf-mhs.com/stg/cds/193)2tpeds-screen-flacc Source of information: mother father other:_Has patient received any type of care since their last visit with this clinic? No YesIs the patient or parent currently in a situation where they are being verbally or physically hurt, threatened, or made to feel afraid? No Yes Declined to answer //Instruction// if Yes perform follow up questions using 2tfpma-screen-domesticviolence and notify provider //Instruction// if Declined to answer, notify provider Edinburgh Postnatal Depression Screen Completed and appropriate action taken as per clinic protocol CDS http://www.fresno.ucsf.edu/pediatrics/downloads/edinburghscale.pdfNormal number of wet diapers a day.Immunizations: Reviewed and current as of: _ Reviewed and recommended: _ Immunizations refused CDS https://www.cdc.gov/vaccines/schedules/hcp/imz/child-adolescent.html http://www.tswf-mhs.com/files/EHR/AIM%20Forms/AIM%20Form%20Documents/Pediatrics/Refusal-to-vaccinate-caregiver-consent.pdf

of 41


2tpeds-screen-annualquestions2tpeds-screen-travelhistory2tpeds-screen-zika2tpeds-screenpretravelcounseling2tpeds-screen-healthliteracy

ROS:2tpeds-ros-quick2tpeds-ros-viral2tpeds-ros-asthma2tpeds-complete-0-24months

Milestones: SOCIAL - EMOTIONAL: [Y] Smiles [Y] Looks at parent [Y] Self-comfortCOGNITIVE: [Y] Indicates boredom when no activity changeCOMMUNICATIVE: [Y] Coos [Y] Different crying for different needsPHYSICAL DEVELOPMENT: [Y] Lifts head and begins to push up when prone[Y] Holds head erect for short period (when held upright)[Y] Diminished newborn reflexes[Y] Symmetrical movement


Visit for 4 month old well child (CDS http://tswf-mhs.com/stg/cds/194)

2tpeds-screen-flacc Source of information: mother father other:_Has patient received any type of care since their last visit with this clinic? No YesIs the patient or parent currently in a situation where they are being verbally or physically hurt, threatened, or made to feel afraid? No Yes Declined to answer //Instruction// if Yes perform follow up questions using 2tfpma-screen-domesticviolence and notify provider //Instruction// if Declined to answer, notify provider Edinburgh Postnatal Depression Screen Completed and appropriate action taken as per clinic protocol CDS http://www.fresno.ucsf.edu/pediatrics/downloads/edinburghscale.pdfNormal number of wet diapers a day.Immunizations: Reviewed and current as of: _ Reviewed and recommended: _ Immunizations refused CDS https://www.cdc.gov/vaccines/schedules/hcp/imz/child-adolescent.html http://www.tswf-mhs.com/files/EHR/AIM%20Forms/AIM%20Form%20Documents/Pediatrics/Refusal-to-vaccinate-caregiver-consent.pdf 2tpeds-screen-annualquestions2tpeds-screen-travelhistory2tpeds-screen-zika2tpeds-screen-pretravelcounseling2tpeds-screen-healthliteracy Nutrition: no change updated in patient’s chart: Social: Nutrition: Diet

ROS:

of 41


2tpeds-ros-quick2tpeds-ros-viral2tpeds-ros-asthma2tpeds-ros-complete-0-24months

Milestones:SOCIAL - EMOTIONAL: [Y] Social smile [Y] Elicits social interactions [Y] Smiles spontaneously [Y] Can calm down on ownCOGNITIVE: [Y] Responds to affection [Y] Indicates pleasure and displeasureCOMMUNICATIVE: [Y] Spontaneous expressive babblingPHYSICAL DEVELOPMENT: [Y] Pushes chest to elbows [Y] Good head control [Y] Symmetry in movements [Y] Begins to roll and reach for objects


Visit for 6 month old well child (CDS http://tswf-mhs.com/stg/cds/195)2tpeds-screen-flacc Source of information: mother father other:_Has patient received any type of care since their last visit with this clinic? No YesIs the patient or parent currently in a situation where they are being verbally or physically hurt, threatened, or made to feel afraid? No Yes Declined to answer //Instruction// if Yes perform follow up questions using 2tfpma-screen-domesticviolence and notify provider //Instruction// if Declined to answer, notify provider.Edinburgh Postnatal Depression Screen Completed and appropriate action taken as per clinic protocol CDS http://www.fresno.ucsf.edu/pediatrics/downloads/edinburghscale.pdfNormal number of wet diapers a day.Immunizations: Reviewed and current as of: _ Reviewed and recommended: _ Immunizations refused CDS https://www.cdc.gov/vaccines/schedules/hcp/imz/child-adolescent.html http://www.tswf-mhs.com/files/EHR/AIM%20Forms/AIM%20Form%20Documents/Pediatrics/Refusal-to-vaccinate-caregiver-consent.pdf Lead Screening: Does your child live in or visit a home or child care facility with an identified lead hazard or a home built before 1960 that is in poor repair or was renovated in the past 6 months? No **Yes** details:_



ROS:2tpeds-ros-quick

of 41


2tpeds-ros-viral2tpeds-ros-asthma2tpeds-ros-complete-0-24months

Milestones:SOCIAL - EMOTIONAL: [Y] Shows pleasure from interaction with parents or othersCOGNITIVE: [Y] Uses visual exploration [Y] Beginning to use oral explorationCOMMUNICATIVE: [Y] Uses a string of vowels (ah, eh, oh) [Y] Enjoys vocal turn takingPHYSICAL DEVELOPMENT: [Y] Sits briefly, leaning forward [Y] Rolls over


Visit for 9 month old well child: (CDS http://tswf-mhs.com/stg/cds/196)2tpeds-screen-flacc Source of information: mother father other:_Has patient received any type of care since their last visit with this clinic? No YesIs the patient or parent currently in a situation where they are being verbally or physically hurt, threatened, or made to feel afraid? No Yes Declined to answer //Instruction// if Yes perform follow up questions using 2tfpma-screen-domesticviolence and notify provider //Instruction// if Declined to answer, notify provider Immunizations: Reviewed and current as of: _ Reviewed and recommended: _ Immunizations refused CDS https://www.cdc.gov/vaccines/schedules/hcp/imz/child-adolescent.html http://www.tswf-mhs.com/files/EHR/AIM%20Forms/AIM%20Form%20Documents/Pediatrics/Refusal-to-vaccinate-caregiver-consent.pdf Lead Screening: Does your child live in or visit a home or child care facility with an identified lead hazard or a home built before 1960 that is in poor repair or was renovated in the past 6 months? No **Yes** details:_ 2tpeds-screen-annualquestions2tpeds-screen-travelhistory2tpeds-screen-zika2tpeds-screen-pretravelcounseling2tpeds-screen-healthliteracy Nutrition: no change updated in patient’s chart: Social: Nutrition: Diet


ASQ Months: 9 Communication:[_] Gross Motor:[_] Fine Motor:[_] Problem Solving:[_]

of 41


Personal/Social:[_]

Milestones:COGNITIVE: [Y] Peekaboo [Y] Object permanence [Y] Looks at booksCOMMUNICATIVE: [Y] Imitates sounds [Y] Points out objects [Y] Stranger anxiety [Y] Seeks parent for comfortPHYSICAL DEVELOPMENT: [Y] Sits well [Y] crawls [Y] Pulls to feet with support


Visit for 15 month old well child : (CDS http://tswf-mhs.com/stg/cds/198)2tpeds-screen-flacc


Source of information: mother father other:_Has patient received any type of care since their last visit with this clinic? No YesIs the patient or parent currently in a situation where they are being verbally or physically hurt, threatened, or made to feel afraid? No Yes Declined to answer //Instruction// if Yes perform follow up questions using 2tfpma-screen-domesticviolence and notify provider //Instruction// if Declined to answer, notify providerImmunizations: Reviewed and current as of: _ Reviewed and recommended: _ Immunizations refused CDS https://www.cdc.gov/vaccines/schedules/hcp/imz/child-adolescent.html http://www.tswf-mhs.com/files/EHR/AIM%20Forms/AIM%20Form%20Documents/Pediatrics/Refusal-to-vaccinate-caregiver-consent.pdf2tpeds-screen-annualquestions2tpeds-screen-travelhistory2tpeds-screen-zika2tpeds-screen-pretravelcounseling2tpeds-screen-healthliteracy Nutrition: no change updated in patient’s chart: Social: Nutrition: Diet


ASQ Months:15 Communication:[_] Gross Motor:[_] Fine Motor:[_]

of 41




Problem Solving:[_] Personal/Social:[_]

Milestones:SOCIAL – EMOTIONAL [Y] Tries to do what you do [Y] Helps in the house [Y] Listens to a storyCOMMUNICATIVE [Y] Says 2 to 3 words [Y] Brings toys over to show youCOGNITIVE [Y] Scribbles [Y] Follows simple commandsPHYSICAL DEVELOPMENT [Y] Bends down without falling [Y] Walks well [Y] Puts block in a cup[Y] Drinks from a cup with very little spilling


Visit for 18 month old well child: (CDS http://tswf-mhs.com/stg/cds/199)2tpeds-screen-flacc

Vision Spot Screener:R SE _/ DS _/ DC _/ Axis @ _ DEGL SE _/ DS _/ DC _/ Axis @ _ DEG Rec. All in range Anisometropia Astigmatism Myopia Hyperopia Anisocoria Gaze Vertical Gaze Nasal Gaze Temporal Gaze Asymmetry , _ Anisometropia Astigmatism Myopia Hyperopia Anisocoria Gaze Vertical Gaze Nasal Gaze Temporal Gaze Asymmetry , _ Anisometropia Astigmatism Myopia Hyperopia Anisocoria Gaze Vertical Gaze Nasal Gaze Temporal Gaze Asymmetry , _ Anisometropia Astigmatism Myopia Hyperopia Anisocoria Gaze Vertical Gaze Nasal Gaze Temporal Gaze Asymmetry Source of information: mother father other:_Has patient received any type of care since their last visit with this clinic? No YesIs the patient or parent currently in a situation where they are being verbally or physically hurt, threatened, or made to feel afraid? No Yes Declined to answer //Instruction// if Yes perform follow up questions using 2tfpma-screen-domesticviolence and notify provider //Instruction// if Declined to answer, notify providerImmunizations: Reviewed and current as of: _ Reviewed and recommended: _ Immunizations refused CDS https://www.cdc.gov/vaccines/schedules/hcp/imz/child-adolescent.html http://www.tswf-mhs.com/files/EHR/AIM%20Forms/AIM%20Form%20Documents/Pediatrics/Refusal-to-vaccinate-caregiver-consent.pdf Lead Screening: Does your child live in or visit a home or child care facility with an identified lead hazard or a home built before 1960 that is in poor repair or was renovated in the past 6 months? No **Yes** details:_


of 41


2tpeds-screen-annualquestions2tpeds-screen-travelhistory2tpeds-screen-zika2tpeds-screenpretravelcounseling2tpeds-screen-healthliteracy Nutrition: no change updated in patient’s chart: Social: Nutrition: Diet


ASQ Months:18Communication:[_] Gross Motor:[_] Fine Motor:[_] Problem Solving:[_] Personal/Social:[_]M-CHAT-R/F 18 months (CDS http://www2.gsu.edu/~psydlr/M-CHAT/Official_M-CHAT_Website_files/M-CHAT-R_F.pdf)Total # of M-CHAT-R Questions Failed:[_] # of M-CHAT-R/F Questions Failed:[_]

Milestones:SOCIAL – EMOTIONAL [Y] Helps in the house [Y] Laughs in response to othersCOMMUNICATIVE [Y] Speaks 6 wordsCOGNITIVE [Y] Knows names of favorite books [Y] Points to 1 body partPHYSICAL DEVELOPMENT [Y] Stacks 2 small blocks [Y] Runs [Y] Walk up steps [Y] Uses spoon and cup without spilling most of the time


Visit for 24 month old well child: (CDS http://tswf-mhs.com/stg/cds/200)2tpeds-screen-flacc

Vision Spot Screener:R SE _/ DS _/ DC _/ Axis @ _ DEGL SE _/ DS _/ DC _/ Axis @ _ DEG Rec. All in range Anisometropia Astigmatism Myopia Hyperopia Anisocoria Gaze Vertical Gaze Nasal Gaze Temporal Gaze Asymmetry , _ Anisometropia Astigmatism Myopia Hyperopia Anisocoria Gaze Vertical Gaze Nasal Gaze Temporal Gaze Asymmetry , _ Anisometropia Astigmatism Myopia Hyperopia Anisocoria Gaze Vertical Gaze Nasal Gaze Temporal Gaze Asymmetry , _ Anisometropia Astigmatism Myopia Hyperopia Anisocoria Gaze Vertical Gaze Nasal Gaze Temporal Gaze Asymmetry Source of information: mother father other:_Has patient received any type of care since their last visit with this clinic? No Yes

of 41


Is the patient or parent currently in a situation where they are being verbally or physically hurt, threatened, or made to feel afraid? No Yes Declined to answer //Instruction// if Yes perform follow up questions using 2tfpma-screen-domesticviolence and notify provider //Instruction// if Declined to answer, notify provider Immunizations: Reviewed and current as of: _ Reviewed and recommended: _ Immunizations refused CDS https://www.cdc.gov/vaccines/schedules/hcp/imz/child-adolescent.html http://www.tswf-mhs.com/files/EHR/AIM%20Forms/AIM%20Form%20Documents/Pediatrics/Refusal-to-vaccinate-caregiver-consent.pdf Lead Screening: Does your child live in or visit a home or child care facility with an identified lead hazard or a home built before 1960 that is in poor repair or was renovated in the past 6 months? No **Yes** details:_




ASQ Months:24Communication:[_] Gross Motor:[_] Fine Motor:[_] Problem Solving:[_] Personal/Social:[_]

M-CHAT-R/F 24 months (CDS http://www2.gsu.edu/~psydlr/M-CHAT/Official_M-CHAT_Website_files/M-CHAT-R_F.pdf)Total # of M-CHAT-R Questions Failed:[_] # of M-CHAT-R/F Questions Failed:[_]

Milestones:SOCIAL – EMOTIONAL [Y] Copies things that you do [Y] Plays pretend [Y] Plays alongside other childrenCOMMUNICATIVE [Y] When talking, puts 2 words together (eg. my book)COGNITIVE [Y] Names 1 picture (eg. cat, dog, ball) [Y] Follows 2-step commandsPHYSICAL DEVELOPMENT [Y] Stacks 5 or 6 blocks [Y] Kicks a ball [Y] Walks up and down stairs 1 step at a time alone while holding wall or railing [Y] Throws ball overhand [Y] Jumps up [Y] Turns book pages 1 at a time

of 41



Visit for 30 month old well child : (CDS http://tswf-mhs.com/stg/cds/201)2tpeds-screen-flacc

Vision Spot Screener:R SE _/ DS _/ DC _/ Axis @ _ DEGL SE _/ DS _/ DC _/ Axis @ _ DEG Rec. All in range Anisometropia Astigmatism Myopia Hyperopia Anisocoria Gaze Vertical Gaze Nasal Gaze Temporal Gaze Asymmetry , _ Anisometropia Astigmatism Myopia Hyperopia Anisocoria Gaze Vertical Gaze Nasal Gaze Temporal Gaze Asymmetry , _ Anisometropia Astigmatism Myopia Hyperopia Anisocoria Gaze Vertical Gaze Nasal Gaze Temporal Gaze Asymmetry , _ Anisometropia Astigmatism Myopia Hyperopia Anisocoria Gaze Vertical Gaze Nasal Gaze Temporal Gaze Asymmetry Source of information: mother father other:_Has patient received any type of care since their last visit with this clinic? No YesIs the patient or parent currently in a situation where they are being verbally or physically hurt, threatened, or made to feel afraid? No Yes Declined to answer //Instruction// if Yes perform follow up questions using 2tfpma-screen-domesticviolence and notify provider //Instruction// if Declined to answer, notify provider Immunizations: Reviewed and current as of: _ Reviewed and recommended: _ Immunizations refused CDS https://www.cdc.gov/vaccines/schedules/hcp/imz/child-adolescent.html http://www.tswf-mhs.com/files/EHR/AIM%20Forms/AIM%20Form%20Documents/Pediatrics/Refusal-to-vaccinate-caregiver-consent.pdf


ROS:2tpeds-ros-quick2tpeds-ros-viral2tpeds-ros-asthma2tpeds-ros-complete-2-6year

ASQ Months:30Communication:[_] Gross Motor:[_] Fine Motor:[_] Problem Solving:[_] Personal/Social:[_]

Milestones:SOCIAL – EMOTIONAL [ Y ] Plays pretend [ Y ] Plays with other children (eg. Tag) [ Y ] Other people can understand what your child is saying half of the time [ Y ] When talking, puts 3 or 4 words together

of 41


COGNITIVE [ Y ] Points to 6 body parts [ Y ] Knows correct animal sounds (eg. Cat meows, dog barks)PHYSICAL DEVELOPMENT [ Y ] Jumps up and down in place [ Y ] Puts on clothes with help [ Y ] Washes and dries hands without help [ Y ] Brushes teeth with help

Abbreviation: 2tpeds-well-3year-screenDescription: Use as base duplication template for creating well child phrases from 3 years through 11-18 years.

Visit for 3 year old well child ( CDS http://tswf-mhs.com/stg/cds/202 )2tpeds-screen-flaccPain(Wong-Baker Faces): 0 1 2 3 4 5 6 7 8 9 10 /10

Vision Spot Screener:R SE _/ DS _/ DC _/ Axis @ _ DEGL SE _/ DS _/ DC _/ Axis @ _ DEG Rec. All in range Anisometropia Astigmatism Myopia Hyperopia Anisocoria Gaze Vertical Gaze Nasal Gaze Temporal Gaze Asymmetry , _ Anisometropia Astigmatism Myopia Hyperopia Anisocoria Gaze Vertical Gaze Nasal Gaze Temporal Gaze Asymmetry , _ Anisometropia Astigmatism Myopia Hyperopia Anisocoria Gaze Vertical Gaze Nasal Gaze Temporal Gaze Asymmetry , _ Anisometropia Astigmatism Myopia Hyperopia Anisocoria Gaze Vertical Gaze Nasal Gaze Temporal Gaze Asymmetry Hearing screen: (Instructions: Children insured by Medicaid Need hearing screen once between the age of 6 months – 4 years and once between the ages of 4-21 years. Document results using the appropriate method.) No Yes Any concern with the patient’s hearing Yes No Does the parent know if a hearing test was done in school? Yes No Was the hearing test normal? Audiometry (Instructions: 3 yrs and older per child’s cooperation)

Left / Right Ear 20 dB 25 dB 40 dB

500 Hz Left Passed / Passed _ / _ _ / _



40000 Hz Left Passed / Passed _ / _ _ / _ Source of information: mother father other:_Has patient received any type of care since their last visit with this clinic? No YesIs the patient or parent currently in a situation where they are being verbally or physically hurt, threatened, or made to feel afraid? No Yes Declined to answer //Instruction// if Yes perform follow up questions using 2tfpma-screen-domesticviolence and notify provider //Instruction// if Declined to answer, notify providerImmunizations: Reviewed and current as of: _ Reviewed and recommended: _ Immunizations refused CDS https://www.cdc.gov/vaccines/schedules/hcp/imz/child-

of 41

http://tswf-mhs.com/stg/cds/202


adolescent.html http://www.tswf-mhs.com/files/EHR/AIM%20Forms/AIM%20Form%20Documents/Pediatrics/Refusal-to-vaccinate-caregiver-consent.pdf

Lead Screening: Does your child live in or visit a home or child care facility with an identified lead hazard or a home built before 1960 that is in poor repair or was renovated in the past 6 months? No **Yes** details:_



ROS:2tpeds-ros-quick2tpeds-ros-viral2tpeds-ros-asthma2tpeds-complete-2-6year

Milestones:SOCIAL - EMOTIONAL [Y] Plays pretend [Y] Plays with other children (eg. Tag) [Y] Other people can understand what your child is saying half of the time [Y] When talking, puts 3 or 4 words together COGNITIVE [Y] Points to 6 body parts [Y] Knows correct animal sounds (eg. Cat meows, dog barks) PHYSICAL DEVELOPMENT [Y] Jumps up and down in place [Y] Puts on clothes with help [Y] Washes and dries hands without help [Y] Brushes teeth with help

Abbreviation: 2tpeds-well-4year-screenDescription:

Visit for 4 year old well child (CDS http://tswf-mhs.com/stg/cds/203)2tpeds-screen-flaccPain(Wong-Baker Faces): 0 1 2 3 4 5 6 7 8 9 10 /10

Vision Spot Screener:R SE _/ DS _/ DC _/ Axis @ _ DEGL SE _/ DS _/ DC _/ Axis @ _ DEG Rec. All in range Anisometropia Astigmatism Myopia Hyperopia Anisocoria Gaze Vertical Gaze Nasal Gaze Temporal Gaze Asymmetry , _ Anisometropia Astigmatism Myopia Hyperopia Anisocoria Gaze Vertical Gaze Nasal Gaze Temporal Gaze Asymmetry , _ Anisometropia Astigmatism Myopia Hyperopia Anisocoria Gaze Vertical Gaze Nasal Gaze

of 41


Temporal Gaze Asymmetry , _ Anisometropia Astigmatism Myopia Hyperopia Anisocoria Gaze Vertical Gaze Nasal Gaze Temporal Gaze Asymmetry

Hearing screen: (Instructions: Children insured by Medicaid Need hearing screen once between the age of 6 months – 4 years and once between the ages of 4-21 years. Document results using the appropriate method.) No Yes Any concern with the patient’s hearing Yes No Does the parent know if a hearing test was done in school? Yes No Was the hearing test normal? Audiometry (Instructions: 3 yrs and older per child’s cooperation)






Source of information: mother father other:_Has patient received any type of care since their last visit with this clinic? No YesIs the patient or parent currently in a situation where they are being verbally or physically hurt, threatened, or made to feel afraid? No Yes Declined to answer //Instruction// if Yes perform follow up questions using 2tfpma-screen-domesticviolence and notify provider //Instruction// if Declined to answer, notify providerImmunizations: Reviewed and current as of: _ Reviewed and recommended: _ Immunizations refused CDS https://www.cdc.gov/vaccines/schedules/hcp/imz/child-adolescent.html http://www.tswf-mhs.com/files/EHR/AIM%20Forms/AIM%20Form%20Documents/Pediatrics/Refusal-to-vaccinate-caregiver-consent.pdf Lead Screening: Does your child live in or visit a home or child care facility with an identified lead hazard or a home built before 1960 that is in poor repair or was renovated in the past 6 months? No **Yes** details:_



of 41


ROS:2tpeds-ros-quick2tpeds-ros-viral2tpeds-ros-asthma2tpeds-ros-complete-2-6year

Milestones:SOCIAL - EMOTIONAL [Y] Interactions with peers [Y] Fantasy play COMMUNICATIVE [Y] Usually understandable [Y] Knows name, age, and gender COGNITIVE [Y] Names 4 colors [Y] Draws person (3 body parts) [Y] Plays board/card games PHYSICAL DEVELOPMENT [Y] Hops on one foot [Y] Balances on one foot for 2 seconds [Y] Builds tower (8 blocks) [Y] Copies a cross [Y] Brushes own teeth [Y] Dresses self


Visit for 5 year old well child (CDS http://tswf-mhs.com/stg/cds/204)2tpeds-screen-flaccPain(Wong-Baker Faces): 0 1 2 3 4 5 6 7 8 9 10 /10








of 41


Source of information: mother father other:_Has patient received any type of care since their last visit with this clinic? No YesIs the patient or parent currently in a situation where they are being verbally or physically hurt, threatened, or made to feel afraid? No Yes Declined to answer //Instruction// if Yes perform follow up questions using 2tfpma-screen-domesticviolence and notify provider //Instruction// if Declined to answer, notify providerImmunizations: Reviewed and current as of: _ Reviewed and recommended: _ Immunizations refused (CDS https://www.cdc.gov/vaccines/schedules/hcp/imz/child-adolescent.html http://www.tswf-mhs.com/files/EHR/AIM%20Forms/AIM%20Form%20Documents/Pediatrics/Refusal-to-vaccinate-caregiver-consent.pdf) Lead Screening: Does your child live in or visit a home or child care facility with an identified lead hazard or a home built before 1960 that is in poor repair or was renovated in the past 6 months? No **Yes** details:_



ROS:2tpeds-ros-quick2tpeds-ros-viral2tpeds-ros-asthma2tpeds-ros-sportsparticipation2tpeds-ros-adhd2tpeds-ros-complete-2-6year

Milestones:MOTOR [Y] Balances on 1 foot [Y] Hops and skips [Y] Able to tie knotLANGUAGE [Y] Good articulation/language skillsLEARNING [Y] Draws person (6+body parts) [Y] Prints some letters and numbers [Y] Copies squares, triangles [Y] Counts to 10 [Y] Names 4 or more colors [Y] Follows simple directions [Y] Listens and attends


Visit for 6 year old well child (CDS http://tswf-mhs.com/stg/cds/205)2tpeds-screen-flacc

of 41


Pain(Wong-Baker Faces): 0 1 2 3 4 5 6 7 8 9 10 /10








Source of information: mother father patient other:_Has patient received any type of care since their last visit with this clinic? No YesIs the patient or parent currently in a situation where they are being verbally or physically hurt, threatened, or made to feel afraid? No Yes Declined to answer //Instruction// if Yes perform follow up questions using 2tfpma-screen-domesticviolence and notify provider //Instruction// if Declined to answer, notify providerImmunizations: Reviewed and current as of: _ Reviewed and recommended: _ Immunizations refused

CDS https://www.cdc.gov/vaccines/schedules/hcp/imz/child-adolescent.html http://www.tswf-mhs.com/files/EHR/AIM%20Forms/AIM%20Form%20Documents/Pediatrics/Refusal-to-vaccinate-caregiver-consent.pdf Lead Screening: Does your child live in or visit a home or child care facility with an identified lead hazard or a home built before 1960 that is in poor repair or was renovated in the past 6 months? No **Yes** details:_

Tuberculosis Screening: Has a family member or contact had tuberculosis? No **Yes** details:_

of 41


Has a family member had a positive tuberculin skin test? No **Yes** details:_Was your child born in a high-risk country? No **Yes** details:_Has your child traveled to a high risk country for more than one week? No **Yes** details:_


ROS:2tpeds-ros-quick2tpeds-ros-viral2tpeds-ros-asthma2tpeds-ros-sportsparticipation2tpeds-ros-adhd2tpeds-ros-complete-2-6year

Milestones:MOTOR [Y] Balances on 1 foot [Y] Hops and skips [Y] Able to tie knotLANGUAGE [Y] Good articulation/language skillsLEARNING [Y] Draws person (6+body parts) [Y] Prints some letters and numbers [Y] Copies squares, triangles [Y] Counts to 10 [Y] Names 4 or more colors [Y] Follows simple directions [Y] Listens and attends

Abbreviation: 2tpeds-well-7-8year-screenDescription:

Visit for 7-8 year old well child (CDS http://tswf-mhs.com/stg/cds/206)Pain: 0 1 2 3 4 5 6 7 8 9 10 /102tpeds-screen-flaccPain(Wong-Baker Faces): 0 1 2 3 4 5 6 7 8 9 10 /10


Hearing screen: (Instructions: Children insured by Medicaid Need hearing screen once between the age of 6 months – 4 years and once between the ages of 4-21 years. Document results using the appropriate method.) No Yes Any concern with the patient’s hearing Yes No Does the parent know if a hearing test was done in school? Yes No Was the hearing test normal?

of 41


Audiometry (Instructions: 3 yrs and older per child’s cooperation)






Source of information: mother father patient other:_Has patient received any type of care since their last visit with this clinic? No YesIs the patient or parent currently in a situation where they are being verbally or physically hurt, threatened, or made to feel afraid? No Yes Declined to answer //Instruction// if Yes perform follow up questions using 2tfpma-screen-domesticviolence and notify provider //Instruction// if Declined to answer, notify providerImmunizations: Reviewed and current as of: _ Reviewed and recommended: _ Immunizations refused CDS https://www.cdc.gov/vaccines/schedules/hcp/imz/child-adolescent.html http://www.tswf-mhs.com/files/EHR/AIM%20Forms/AIM%20Form%20Documents/Pediatrics/Refusal-to-vaccinate-caregiver-consent.pdf Tuberculosis Screening: Has a family member or contact had tuberculosis? No **Yes** details:_Has a family member had a positive tuberculin skin test? No **Yes** details:_Was your child born in a high-risk country? No **Yes** details:_Has your child traveled to a high risk country for more than one week? No **Yes** details:_


ROS:2tpeds-ros-quick2tpeds-ros-viral2tpeds-ros-asthma2tpeds-ros-sportsparticipation2tpeds-ros-adhd2tpeds-ros-complete-female-7-18year2tpeds-ros-complete-male-7-18year

Milestones:DEVELOPMENT[Y] Eats healthy meals and snacks[Y] Participates in an after-school activity[Y] Has friends[Y] Is vigorously active for 1 hour a day[Y] Is doing well in school[Y] Does chores when asked

of 41


[Y] Gets along with family


Visit for 9-10 year old well child: (CDS http://tswf-mhs.com/stg/cds/207)Pain: 0 1 2 3 4 5 6 7 8 9 10 /102tpeds-screen-flaccPain(Wong-Baker Faces): 0 1 2 3 4 5 6 7 8 9 10 /10








Source of information: mother father patient other:_Has patient received any type of care since their last visit with this clinic? No YesIs the patient or parent currently in a situation where they are being verbally or physically hurt, threatened, or made to feel afraid? No Yes Declined to answer //Instruction// if Yes perform follow up questions using 2tfpma-screen-domesticviolence and notify provider //Instruction// if Declined to answer, notify providerImmunizations: Reviewed and current as of: _ Reviewed and recommended: _ Immunizations refused CDS https://www.cdc.gov/vaccines/schedules/hcp/imz/child-adolescent.html http://www.tswf-mhs.com/files/EHR/AIM%20Forms/AIM%20Form%20Documents/Pediatrics/Refusal-to-vaccinate-caregiver-consent.pdf

of 41







Milestones:DEVELOPMENT[Y] Eats healthy meals and snacks[Y] Participates in an after-school activity[Y] Has friends[Y] Is vigorously active for 1 hour a day[Y] Has a caring/supportive family[Y] Is doing well in school[Y] Is getting chances to make own decisions[Y] Feels good about self[Y] Does an activity really well; describe:_


Visit for 11-18 year old well child: (CDS http://tswf-mhs.com/stg/cds/207)Pain: 0 1 2 3 4 5 6 7 8 9 10 /102tpeds-screen-flaccPain(Wong-Baker Faces): 0 1 2 3 4 5 6 7 8 9 10 / 10


of 41








Source of information: mother father patient other:_Has patient received any type of care since their last visit with this clinic? No YesIs the patient or parent currently in a situation where they are being verbally or physically hurt, threatened, or made to feel afraid? No Yes Declined to answer //Instruction// if Yes perform follow up questions using 2tfpma-screen-domesticviolence and notify provider //Instruction// if Declined to answer, notify providerImmunizations: Reviewed and current as of: _ Reviewed and recommended: _ Immunizations refused (CDS https://www.cdc.gov/vaccines/schedules/hcp/imz/child-adolescent.html http://www.tswf-mhs.com/files/EHR/AIM%20Forms/AIM%20Form%20Documents/Pediatrics/Refusal-to-vaccinate-caregiver-consent.pdf)

2 Question Depression Screening:Over the last 2 weeks, how often have you been bothered by any of the following problems? 0-not at all 1-several days 2-more than half the days 3-nearly every day 1) Little Interest or pleasure in doing things Feeling down, depressed, irritable, or hopeless. 0-not at all 1-several days 2-more than half the days 3-nearly every day 2) Feeling down, depressed or hopeless.2 Question Depression Screen result: Negative **Positive**, CDS (a positive screen is 2 or 3 on either question)2tpeds-screen-phq9a2tpeds-screen-crafft

Tuberculosis Screening: Has a family member or contact had tuberculosis? No **Yes** details:_Has a family member had a positive tuberculin skin test? No **Yes** details:_Was your child born in a high-risk country? No **Yes** details:_Has your child traveled to a high risk country for more than one week? No **Yes** details:_ 2tpeds-screen-annualquestions2tpeds-screen-travelhistory2tpeds-screen-zika2tpeds-screen-pretravelcounseling

of 41

http://www.tswf-mhs.com/files/EHR/AIM%20Forms/AIM%20Form%20Documents/Pediatrics/Refusal-to-vaccinate-

http://www.tswf-mhs.com/files/EHR/AIM%20Forms/AIM%20Form%20Documents/Pediatrics/Refusal-to-vaccinate-




2tpeds-screen-healthliteracy Nutrition: no change updated in patient’s chart: Social: Nutrition: Diet


HEADSSS Assessment: CDC???? H: _ E: _ A: _ D: _ S: _ S: _ S: _

Abbreviation: 2tpeds-ssp-b12Description:

Vitamin B12:S: - Yes No Written order verified from provider to administer Vitamin B12 IM injection. - Yes No 2 patient identifiers verified - Yes No Patient has picked up current B-12 prescription from pharmacy Exclusion criteria - Yes No Patient does NOT have excessive fatigue (Symptoms worse than initial assessment)? - Yes No Patient has normal vital signs (SBP 90-140, DBP 60-90, Pulse 60-90, RR <24, Temp <101.5)O: - Yes No Current allergy status shows no contraindications, no prior history of adverse reaction to Vitamin B12 injections.

[ Insert Labs Last 6 Months 2012 Smart Template] Procedure: Vitamin B12 IM Please refer to MAR for medication details

A/P: 1. Patient tolerated medication without adverse reactions.

of 41


2. Next date due for injection: [_]

Abbreviation: 2tpeds-ssp-depoproveraDescription:

Depo-Provera:S: - Yes No Provider has prescribed Depo-Provera birth control for patient, current order validated - Yes No Pap smear is current is not current, patient was scheduled an appointment to obtain

//Instructions// Choose an option below: Within 5 days of onset of normal menses. First day of LMP: _ Neg HCG today; States been abstinent for 2 weeks. Repeat injection. Presents within window Date of last injection: _ Date injection due: _ Presents outside injection window; not given today.

Exclusion criteria: - No **Yes** Pregnancy or pregnancy symptoms - No **Yes** Prolonged/ongoing headaches - No **Yes** Heavy vaginal bleeding - No **Yes** Depression symptoms - No **Yes** New diagnosis of thrombophlebitis or thromboembolic disease (blood clots, stroke, heart attack) - Yes **No** Patient has normal vital signs (SBP 90-140, DBP 60-90, Pulse 60-90, RR <24, Temp <101.5)No exclusion criteria met **exclusion criteria present** provider notifiedO: - Yes No 2 patient identifiers met Procedure: Depo-Provera injection Please refer to MAR for medication details

A/P: 1. Patient tolerated medication without adverse reactions. 2. Next date due for injection: [_] (CDS //Instructions// update in Diagnoses and Problem List in "dark menu", "contraception care", change title to Depo-provera next shot due (date).)

Abbreviation: 2tpeds-ssp-testosteroneDescription:

Testosterone:S: -Yes No Provider has prescribed testosterone injection for patient, current order validated Exclusion criteria: - No **Yes** Hypersensitivity to testosterone - No **Yes** History of male breast or prostate cancer - No **Yes** Women who are breast-feeding, pregnant or may become pregnant - No **Yes** New coumadin therapy (excessive edema. Excessive bleeding or bruising) - No **Yes** Liver function tests performed in the last 12 months

of 41


- No **Yes** Patient has normal vital signs (SBP 90-140, DBP 60-90, Pulse 60-90, RR <24, Temp <101.5)No exclusion criteria met **exclusion criteria present** provider notifiedO: - Yes No 2 patient identifiers met

[ Insert Labs Last 18 Months 2012 Smart Template] Procedure: Testosterone injection Please refer to MAR for medication details

A/P: 1. Patient tolerated medication without adverse reactions. 2. Next date due for injection: [_] ( CDS //Instructions// update in Diagnoses and Problem List in "dark menu", "testosterone deficiency", change title to testosterone next shot due (date). )

Abbreviation: 2tpeds-ssp-synagisDescription:

Synagis:S: -Yes No Provider has prescribed Synagis injection for patient (2years of age and below), current order validated Exclusion criteria: - No **Yes** Hypersensitivity (allergic reaction) to palivizumab or murine antibody - No **Yes** Acute bronchospasm - No **Yes** Hypotension - No **Yes** Thrombocytopenia, hemophilia, or anticoagulation therapy - Yes **No** Patient has normal vital signs ( Temp <101.5 premature: P 120-170, BP 65-85/45-55, RR 40-70 0-3 months P 100-150, BP 70-90/50-65, RR 30-45 3-6 months P100-150, BP 70-90/50-65, RR 30-45 6-12 months P 90-130, BP 80-100/55-65, RR 25-40 1-3 years P 80-125, BP 90-105/55-70, RR 20-30 )

No exclusion criteria met **exclusion criteria present** provider notified

O: - Yes No 2 patient identifiers met

Procedure: Synagis injection Please refer to MAR for medication details

A/P: 1. Patient tolerated medication without adverse reactions. 2. Follow up: PRN For booster within:

Abbreviation: 2tpeds-ssp-dysuriaDescription:

Dysuria SSP:

of 41


S: _ - Yes No Dysuria (pain/burning) - No Yes Frequent urination - No Yes Urinary urgency Exclusion Criteria: - No **Yes** Is the patient < 18 or > 64 years old? - No **Yes** Is this the patient’s first time experiencing UTI-like symptoms? - No **Yes** Has the patient been treated for 3 or more UTIs in the past 12 months? - No **Yes** Is the patient pregnant or possibly pregnant (e.g. late/missed menstrual cycle)? - No **Yes** Is the patient in a perioperative (pre or post-operative) status, been hospitalized or received a urinary catheter within the last 7 days? - No **Yes** Is the patient complaining of vaginal discharge and/or itching? - No **Yes** Is the patient complaining of ulcers, rashes or blisters in the genital area? - No **Yes** Does the patient experience pain with intercourse? - No **Yes** Does the patient have a history of kidney or urological diseases (e.g. kidney transplants, stones or procedures; urinary obstruction, abnormalities or urologic anatomic defects)? -No **Yes** Does the patient have severe abdominal, pelvic or flank pain? -No **Yes** Does the patient have nausea or vomiting? -No **Yes** Has the patient measured a fever at home of greater than 100.4o F/38oC? -No **Yes** Does the patient have a decreased immune system due to either medications (e.g. steroids or immunosuppressive agents for Rheumatoid Arthritis) or diseases (e.g. cancer or HIV)? -No **Yes** Does the patient have Diabetes Mellitus? Patient responded "No" to all questions above "Yes" to one or more of the questions above, provider alerted Allergies/Sensitivities: All other allergies verified: Y Nitrofurantoin: N Y Trimethoprim/Sulfamethoxazole and/or does the MTF have >20% antibiotic resistance data? No Yes Fosfomycin Trometamol: No YesO: Vital signs noted as below:

Pt vital signs: WNL Abnormal after repeat, provider alerted Plan:Care Transferred: N/A other: Labs to be ordered: Urinalysis No Yes Urine Culture No Yes Urine HC: No Yes GC/Chlamydia: No YesMedications to be ordered: Nitrofurantoin: No Yes Trimethoprim/Sulfamethoxazole: No Yes Fosfomycin Trometamol: No Yes

Patient education, counseling and follow-up care instructions were discussed with the patient and the patient conveyed understanding. Annotate instructions below (e.g. patient to follow-up with PCM if not responsive to medication regime within 2-3 days).

of 41


Abbreviation: 2tpeds-ssp-sorethroatDescription:

Sore Throat:S: Patient with a history of sore throat for # [_] days; presents to the clinic for throat swab per clinic protocol. - No Yes //Instructions// If Yes, then obtain strep and/or culture, notify provider Patient had recent exposure to strep and has symptoms Pain: 0 1 2 3 4 5 6 7 8 9 10 /10 - No Yes Decreased food intake - No Yes Decreased fluid intakeExclusion criteria: -No **Yes** Symptoms (sore throat or fever) more than 10 days? -No **Yes** Accompanying complaints or Chronic conditions: Earache, COPD, Diabetes, Chemotherapy, Immunosuppressive drugs, Significant cough, Asthma, HIV/AIDS, or Pregnancy? -N **Yes** More than 2 Strep infections within the last 12 months? -N **Yes** Sat % less than 95% with distress? -N **Yes** Any shortness of breath, or wheezing? -N **Yes** Any drooling, difficulty swallowing, or uvular deviation? Pediatric patient with normal vital signs Temp <101.5, RR<25, P (age 3-6 yrs 70-115) (age 7-18 yrs 60-10) Pediatric patient with abnormal vital signs after repeat, provider alerted Adult Patient with normal vital signs (SBP 90-140, DBP 60-90, Pulse 60-90, RR <24, Temp <101.5) Adult Patient with abnormal vital signs after repeat, provider alertedO:

No Yes Throat erythemaNo Yes Exudate presentNo Yes Excess salivationNo Yes Difficulty Opening MouthNo Yes Severe and/or one sided Tonsillar swellingNo Yes Marked Swelling and Tenderness of Cervical Lymph NodesNo Yes RashNo Yes Foul smelling breath

SSP SCORING:0=No 1=Yes Is cough absent?0=No 1=Yes Is there a history of fever > 100.4F?0=No 1=Yes Is there tonsillar swelling or exudate?0=No 1=Yes Are there swollen tender anterior nodes?0=No 1=Yes Is patient age 3-14 years?0=No -1=Yes (Adult patients) Is pt age >44 years? (subtracts from score)[_] Centor Score

A: Probable strep pharyngitis (recent exposure and has symptoms, or score >3) Possible strep pharyngitis (score 2-3) Viral pharyngitis (score 0-1)

P: Rapid strep or culture obtained, provider to assess pt and order treatment, home care instructions and medication education given Rapid strep or culture obtained, home care instructions given, results will be reported to provider No antibiotics or throat swab performed, home care instructions given, pt to F/U if symptoms persist or worsen

of 41


Abbreviation: 2tpeds-ssp-wartDescription:

Wart treatment: S: Patient presents at follow up visit with for new complaint of warts on [_]. No redness or swelling at the site is noted. Exclusion criteria: -No **Yes** Does the patient have a fever? -No **Yes** Does the patient have any redness at the wart site or treatment site? -No **Yes** Does the patient have any swelling at the wart site or treatment site? Patient answered "No" to all questions above "Yes" to one or more of the questions above, provider alerted Warts are treated per: Clinic protocol Provider instruction O: Pediatric patient with normal vital signs Temp <101.5, RR<25, P (age 3-6 yrs 70-115) (age 7-18 yrs 60-110) Pediatric patient with abnormal vital signs after repeat, provider alerted

A: Wart/s is noticeably smaller in size measuring is noticeably larger in size measuring measure at: [_] cm P: The wart/s was treated with: Cryotherapy: Nozzle was positioned 1-1.5cm above skin surface, aimed at center of wart. Liquid Nitrogen applied until ice field encompassed wart and margin (2-3mm). Freeze thaw technique performed with 2-3 minutes between cycles. Topical agent. Salicylic acid.Procedure completed by: [ Username ], Medical TechnicianTime of procedure: _- Yes No Treatment options and side effects discussed with patient- Yes No Verbal/written informed consent (as per local MTF policy) obtained from patient or parent/guardian- Yes No Universal precaution and time out procedures were initiated- Yes No Pt given home care instructions and educational materials - Yes No Pt scheduled a follow up appointment per physician orders

Abbreviation: 2tpeds-ssp-pregnancytestDescription:

Pregnancy Test:S: Pregnancy test is requested: Patient denies complaints of cramping, illness and severe nausea.Exclusion criteria -No **Yes** Does the patient have fever or chills? -No **Yes** Does the patient have moderate or severe abdominal pain? -No **Yes** Does the patient have heavy vaginal bleeding (more than the normal menstrual cycle)? Patient answered "No" to all questions above "Yes" to one or more of the questions above, provider alerted - Yes No Patient menstrual cycle is over 5 days late - Yes No Home pregnancy test completed and was positive

of 41


Patient answered "Yes" to either/both questions above: HCG ordered as per clinic protocol "No" to both questions, patient instructed to return for testing at least 5 days after missed period.

-Is patient between 16 and 24? Yes No --If Yes, has chlamydia screening been completed in the past 12 months? Yes - Date: No ---If not done in 12 months, or overdue, discussed the importance of chlamydia screening and procedure for testing with the patient? Yes No ---Patient consented, test ordered and patient sent to laboratory declined testing First day of last menstrual period: _ [Gravida] _ //Instructions// Update in Histories: Pregnancy as needed O: Procedure completed by: [username] Time of procedure: [_] A: Unconfirmed pregnancy P: -Serum qualitative beta HCG ordered per clinical protocol provider order. Patient sent to lab. -Patient contact information has been verified. -Pt instructions given as follows: PCMH Team will contact patient with pregnancy test results and further instructions within 24 hrs. Positive results: Referral to obstetrical care has been placed, Pre-natal vitamins ordered (no contraindications noted), Active duty referred to Public health for workplace eval/counseling and profile

of 41