Transcription of COMPREHENSIVE PEDIATRIC NURSING ASSESSMENT
1 Primary Diagnosis/Reason for Home CareICD Code(Locator #11)a. _____ ( _____ ) Date _____ O EOther Diagnosis/ReasonsICD Code(Locator #13)b. _____ ( _____ ) Date _____ O Ec. _____ ( _____ ) Date _____ O Ed. _____ ( _____ ) Date _____ O Ee. _____ ( _____ ) Date _____ O Ef. _____ ( _____ ) Date _____ O EHistory/Surgical ProcedureICD Code(Locator #12)_____ ( _____ ) Date _____ O E_____ ( _____ ) Date _____ O EPatient s HI Claim No.: (Locator #1) Same as Medicaid CHIP (Childrens Health Insurance Program) Self or family pays full or partial costs Other_____Gender: (Locator #9) 1-Male 2-FemaleEthnicity and Race: American Indian or Alaska Native Native Hawaiian or AsianPacific Islander Black or African-American White Hispanic or Latino OtherMedicaid Provider Number: (Locator #5) _____Patient ID / Medical Record Number: (Locator #4)_____ Start of Care Date: (Locator #2) _____month/day/yearCertification Period.
2 (Locator #3) (if applicable)From _____ To _____Patient s Name: (Locator #6)_____ ____ (First)(MI)_____(Last)(Suffix)Patient Phone: _____ - _____ - _____Patient Address: (Locator #6)_____(Street/Apt. No.)_____(City)Patient State of Residence: (Locator #6)_____Patient Zip Code: (Locator #6) _____ _____Email Address:_____Birth Date: (Locator #8) _____month/day/yearMedicaid/Waiver Number: NA-No Medicaid(specify waiver)_____PATIENT REPRESENTATIVE INFORMATION (see page 8) COMPREHENSIVE PEDIATRICNURSING ASSESSMENTWITH PLAN OF TREATMENT/485 INFORMATIONPATIENT NAME Last, First, Middle InitialID# COMPREHENSIVE PEDIATRICNURSING ASSESSMENTPage 1 of 14 DATE OF SERVICE _____TIME IN _____ OUT _____ALLERGIES.
3 (Locator #17) None known Aspirin Penicillin Sulfa Pollen Eggs Milk products Insect bites Other_____IMMUNIZATIONS (check if current) DPT Measles Polio DT Mumps HBV MMR Rubella HibIs the patient from birth to 18 years currentwith the recommended CDC immunizationschedule? Yes No UnknownIf no, (specify) _____ Other (specify)_____PERTINENT BACKGROUND INFORMATION PRIMARY REASON FOR HOME HEALTH: _____PERTINENT HISTORY AND / OR PREVIOUS OUTCOMES_____ _____HOSPITALIZATIONS: No hospitalization within 90 days Yes Number of times _____ Hospitalization: 31-90 days 15-30 days 8-14 days In the last 7 daysReason(s)_____WELL CHILD CARE (if applicable)_____ _____ Clinic last visit _____ Next visit _____Form 3547 RPRev.
4 4/18 2002 BRIGGS, Des Moines, IA (800) 247-2343 Unauthorized copying or use violates copyright law. Referring Physician / Pediatrician NPI: UK-Unknown or Not Available_____Phone: (Locator #24) _____ - _____ - _____Name: (Locator #24) _____ ____(First)(MI)_____ (Last)(Suffix)Address: (Street/Apt. No.) (Locator #24)_____City: (Locator #24)_____ State: (Locator #24)Zip Code: (Locator #24)_____ _____Complete upper section according to organization guidelines Private insurance Qualified health planEMERGENCYPREPAREDNESSPRIORITY CODE:Does the patient have an Advance Directives order?
5 No Ye s Address the patient s individualized emergency plan for emergencycontact information. (Briggs form 3556)PATIENT NAME Last, First, Middle InitialID# COMPREHENSIVE PEDIATRICNURSING ASSESSMENTPage 2 of 14 PERTINENT BACKGROUND INFORMATION (Cont d.)SKILLED OBSERVATION / ASSESSMENT (Cont d.)SKILLED OBSERVATION / ASSESSMENTCONDITIONHNPCONDITIONHNP*Thrus h*ApneaConjunctivitisCroupPicaRubellaRub eolaScarlet FeverMumpsChickenpoxHepatitisSickle CellLead poisoningHIVP neumoniaAsthmaFrequent coldsStrep throatSinusitisNosebleedsFracture(s)Burn (s)Otitis mediaFrequent ear infectionTonsillitisFrequent sore throatBleeding problemsRheumatic feverHeadachesSeizures grand malSeizures petit malOther (specify)CHILDHOOD HISTORY(H - History of; N - Negative.)
6 P - Present problem)Newborn screen results_____Gestational age at birth _____ weeksBirth weight less than 1500 g: Yes NoBirth wt. _____lb. _____oz. Length circumference_____ Chest circumference_____Fontanels: Anterior PosteriorUmbilicus: Healed Hernia Inverted EvertedMaternal health problem during pregnancy: Yes No (if known,specify)_____NOTE:Additional newborn/infant related ASSESSMENT criteria are identified by an asterisk (*) throughout the remainder of this all applicable:Mental Status.
7 (Locator #19) Oriented Comatose Forgetful Depressed Hyperactive Disoriented Lethargic Agitated Other_____Vitals: Temperature_____ F C Oral Axillary Tympanic Rectal Pulse:_____ Radial Apical Brachial Carotid Regular Irregular Heart Sounds: Regular IrregularBlood Pressure: Arm Leg Lying Sitting Standing Right_____ Left_____ Weight:_____ Actual ReportedLength/Height:_____ Actual ReportedRespirations_____ Regular Irregular Breath Sounds: Clear Crackles Rales Rhonchi Wheeze Other_____ Diminished Absent Location _____O2saturationat _____%COGNITIVE STATUS/ABILITYUses language to communicate?
8 Yes No Understood Usually understood (has trouble finding words but if given time little orno prompting needed) Often understood (Difficulty finding words and needs lots of prompting) Sometimes understood (has limited ability but is able to make understandable request such as food, drink, toilet) Rarely or never understood Communication device (specify)_____ Not applicable (specify)_____EYES /EARS Glasses Contacts: R L Prosthesis R L Jaundice Blurred vision Legally blind Sunset sign Tracks with eyes Drainage: R L(specify)_____ Most recent eye exam (date)_____ Infections _____ Other (specify, incl.)
9 History)_____ NO PROBLEM HOH: R L Deaf: R L Hearing aid: R L Ear device (cochlear implant) R L Vertigo Tinnitus Most recent hearing exam (date)_____Infections: Yes No If yes, frequency_____ tubes present: Yes No R L Other _____ NO PROBLEMHEAD /NECK6 months and Under: Bulging Fontanel Depressed Fontanel Hydrocephaly Separated Sagittal Suture Microcephaly6 months and Over: Head Asymmetry Head lag Enlarged Head Other_____ Injuries /Wounds (specify)_____ Masses Nodes: Site_____Size_____ Other (specify, incl.
10 History) _____ NO PROBLEMNEWBORN / INFANT (Complete if applicable)SCREENING / EARLY DETECTIONDid the newborn have a state specific Recommended UniformScreening Panel (RUSP)? Yes No UnknownDid the RUSP identify any significant organic conditions or disorders? Yes No Unknown(specify)_____TB skin test: No Yes, if yes,date_____ results_____Lead screening: No Yes, if yes,date_____ results_____Other (specify)_____PROGNOSIS (Locator #20) 1-Poor 2-Guarded 3-Fair 4-Good 5-Excellent PATIENT NAME Last, First, Middle InitialID# COMPREHENSIVE PEDIATRICNURSING ASSESSMENTPage 3 of 14 NOSE / THROAT / MOUTHCARDIOPULMONARY (Cont d.
