MEDICAL-IN-CONFIDENCE HEALTH VISITOR COPY

6 to 8 Week Assessment (Gestational Age) IF THE CHILD IS MORE THAN 12 WEEKS OLD PLEASE USE AN 'UNSCHEDULED' FORM

SCHEDULED DATE OF ASSESSMENT: ACTUAL DATE OF ASSESSMENT:

CHI NO HB
GENDER
HEALTH VISITOR
TREATMENT CENTRE
GP
PLEASE PRINT CLEARLY IN BALL POINT PEN EDD
Please check the information above and if appropriate, enter amendments below. Please also advise the GP of any changes.
Change of name to: Change of GP to:

Change of TC to: CHSP PS SIRS Change of Caseload HV to:

Change of address to: Postcode:

Carer present with child at review (Y) Primary Additional Current

carer carer Other LAC Status

Ethnicity: * Is English 1st language at home? (Y/N) * Bilingual/multilingual (Y/N) *

Vitamin K given I/M (Y/N) * Oral (Y/N) * Blood Spot Results *
Primary carer current smoker (Y/N) Child exposed to 2nd hand smoke (Y/N) PKU

CHT
FEEDING:-
CF
Ever breast fed (Y/N)
* Always exclusively breast fed (Y/N)
*
MCD

Current feeding (previous 24 hours) Child's age when breast feeding stopped: Weeks *Days * HBO

(B, F, M, O, U)

Sleeping: (Y/N) Prone Supine Side Newborn Hearing R * L *

Screening Results

Concerns raised by carer, enter (R)

Feeding/Diet Growth/Weight Sleep Development Physical Health Other

Development outcome of assessment: N - No Concerns C - Concern newly suspected P - Concern/Disorder previously identified X - Assessment incomplete

Gross Motor Speech, Language Social

skills Hearing & Communication Vision Awareness

Tools: - indicate all used during the review to support developmental assessment (see over for codes)

Physical examination: Length (cms) Weight (kg) OFC (cms) Date measured

For each of the items below, enter N - normal, A - abnormal, D - doubtful or uncertain, I - not done/incomplete.

Heart Hips R L Testes R L Genitalia Femoral Pulses R L Eyes: (red reflex) R L

Future action: enter code if applicable P - Provide S - Signposted to D - Discuss with R - Request assistance from W - Refused

Parenting
Speech & Community
GP Support Audiology Language Paediatrics
CAMHS Childsmile

Smoking
Early Financial Other
Cessation CHW Education Advice Services Social Work Physio/OT Services

Summary: list any issues likely to be relevant to the child's ongoing health, development or well-being.
PLEASE PRINT CLEARLY ENTER ISSUE STATUS
Issue Status Read Code

(1)

(2)

(3)

(4)

Recall to HV in wks Appt - enter S, M, L Reason for recall

Health Plan Indicator (HPI) * Updated HPI Support Needs Status *

Summary comment

Practitioners involved in review

(enter Y for all that apply) HV Staff Nurse Nursery Nurse/FSW GP Other

Place of review
(enter Y for all that apply) Home Clinic GP Practice Other

Signature Print Name HV No

Signature Print Name

ver 1.9.15 181215

 CHILD HEALTH PROGRAMME – PRE-SCHOOL
Items marked with an * will be pre-printed with data, if already recorded on the system

Current LAC Status

0 Not currently looked after by local authority
1 Looked after at home
2 Looked after with friends/relatives (placed with friends or relatives who are not approved foster carers)
3 Looked after with foster carers (placed with approved foster carers provided by or purchased by the local authority
4 Looked after with prospective adopters
5 Looked after in other community placement (eg supported accommodation, hospital)
6 Looked after in residential care (any form of residential care eg local authority or voluntary children’s home or crisis care refuge)

Ethnicity Code List

This code list was developed for the 2011 census and is the agreed national NHS Scotland standard list.
Code 99 indicates that the individual was not asked, if they decline to answer code 98 should be used
Group A - White Group D - African
1A Scottish 4D African, African Scottish or African British
1B Other British 4Y Other African
1C Irish
1K Gypsy / Traveller Group E – Caribbean or Black
1L Polish 5C Caribbean, Caribbean Scottish or Caribbean British
1Z Other white ethnic group 5D Black, Black Scottish or Black British
5Y Other Caribbean or Black
Group B – Mixed or Multiple Ethnic Groups
2A Any mixed or multiple ethnic groups Group F - Other Ethnic Group
6A Arab, Arab Scottish or Arab British
Group C – Asian, Asian Scottish or Asian British 6Z Other ethnic group
3F Pakistani, Pakistani Scottish or Pakistani British
3G Indian, Indian Scottish or Indian British Group G – Refused / Not Provided By Patient
3H Bangladeshi, Bangladeshi Scottish or Bangladeshi British 98 Refused / Not provided by patient
3J Chinese, Chinese Scottish or Chinese British
3Z Other Asian, Asian Scottish, Asian British Group H – Not Known
99 Not known

Current Feeding Blood Spot Results

B Breast milk only BLANK No result
F Formula milk only NORM Not suspected
M Mixed breast and formula milk REF Suspected (Referred to Specialist)
O Other VER Awaiting verification
U Unknown UNKN Unknown / Unavailable
RFSD Refused / Declined
LATE Late tested (CF only)
Tools used to support developmental assessment NONE Test not done
01 PEDS 07 SSLM
02 PEDS:DM 08 M-CHAT Newborn Hearing Screening Results
03 ASQ 3 09 Eyberg CBI P Pass
04 SOGS II 10 Other R Refer
05 SDQ 11 None W Withdrawn
06 ASQ:SE I Not done / Incomplete

Issue Status Code

When an issue is entered for the first time, the issue status code must be entered.
Subsequent pre-printed issues must have status updated in the issue status column
0 Referred /Assistance requested
1 Issue ongoing
(#) 2 No longer has issue
(#) 3 Amend issue (must add new issue)
4 No information available
(#) 5 Issue/Code incorrectly recorded
6 Discharged due to DNA
NB SYMBOL (#) INDICATES USE OF THIS CODE WILL CLOSE A PROBLEM

Health Plan Indicator (HPI) Support Needs Status

C Core Programme 0 Not active on SNS
A Additional Programme 1 Active – not yet notified to Doctor
U Unknown 2 Active – not yet assessed
3 Active – being assessed
4 Previously on SNS
8 No Planned Assessment

6 – 8 WEEK ASSESSMENT 160215