Prenatal Care Coordination REASSESSMENT Trimester ______

Instructions available in the Prenatal Care Coordination Operational Guidelines.

PNCC Agency: / PNCC Contact:
MCO: Anthem MHS MDwise Fee-For-Service / MCO Contact Person:
MCO Phone: / MCO
Fax: / Code: H1004 / MCO Pre-Notification #
Prim Physician: / Phone / Fax
Date 1st
Encounter: / Type: HV Clinic
Office Other: / Date 2nd
Encounter / Type: HV Clinic Office Other:
SECTION I — GENERAL INFORMATION – membeR UDATE
1. Member Name: / 2. RID
3. Address / 4. EDC:
5. Phone / 6. E-mail
7. Best way to contact member? / 8. Best time to contact member?
MEMBER REVIEW / Encounter Notes
9. Other ways to contact member
10. Change in insurance status
11. Change in Medical Provider or Clinic
12. Change in EDC:
13. Other:
section ii – CURRENT PREGNANCY
14. Number of prenatal visits to date (list)
15. Next prenatal care appointment (date)
16. Missed appointments?
17. Timing of pregnancy?
18. Barriers to keeping appointments?
19. E.R. 2 or more times during this
pregnancy?
19a. Hospitalized during this pregnancy?
20. HIV risk (partners, unprotected sex)
20a. hiv test during pregnancy?
21. Cultural practices that impact care?
22. Thinking of breastfeeding?
23. Dental visit during pregnancy?
SECTION iII - Pregnancy concerns
24. Does member have or has she had any of the following conditions? (Check all that apply)
Active Cancer / Diabetes / Oligo or poly hydramnios
Active Hepatitis B or C / Exposure to communicable
disease/infection / On methadone
ADHD / Physical disability
Anemia / Gestational Diabetes / Placental Problems (including Previa)
Asthma daily meds / Group B Strep / Pre-eclampsia/Eclampsia
Anxiety / HELLP / Preterm labor
Bipolar / HIV/AIDS / PROM
Boderline Personality / Hypertension / Repeat UTI/ Pyelonephritis
Cardiac conditions / Illness since last visit/Fever / Rh Negative
Chlamydia, gonorrhea, genital herpes / Incompetent cervix / Seizures/epilepsy on meds
Clinical depression / Intellectual disability / Swelling, H/A, blurred vision
Decreased fetal movement / Lupus / Thyroid disease on meds
25. Other illnesses, infections, or conditions requiring medical attention (Describe):
SECTION IV - NUTRITION / WEIGHT / Encounter notes
26. Taking prenatal vitamins? Yes No
27. Change in eating habits? Yes No
28. Food insecurity? Yes No
29. Foods allergies/avoidance? Yes No
30. Cultural foods/herbs Yes No
31. WIC/getting vouchers Yes No
32. Hx of weight loss surgery? Yes No
33. History of eating disorder? Yes No
34. Problems (appetite, indigestion, n/v,
constipation)
35. PICA (non-food items craved or
consumed)
36. Diet Assessment /Physical Activity Review & Evaluation: Note Any Changes Since Previous Encounters
a. Inadequate dairy intake (Ex: < 3 cups)
b. Inadequate fruit intake (Ex: <4½ cup)
c. Inadequate vegetable intake
(Ex: <5-6 ½ cups)
d. Inadequate meat/bean intake
(Ex: <2-3 oz servings)
e. Inadequate grain intake
(Ex: < 6-1 oz serving)
f. Inadequate fluid intake
(Ex: <7 glasses/day)
g. Excess sugar sweetened drinks
(Ex: >1/day)
h. Excess intake of caffeine
(Ex: >3/day)
i. Excess bakery or snack foods
(Ex: >5 /week)
j. Lunch meat or soft cheese
(Ex: deli meats or non-pasteurized
cheeses)
k. Excess fast/convenience meals
(Ex: >10 /week)
l. Inadequate physical activity
(Ex:<30 min/5 days/wk)
m. other
37. Current Weight
a. BMI from initial assessment
38. Weight gain/loss (amount)
39. Weight Gain Outside IOM Guidelines
SECTION V - SUBSTANCE USE ( Check all that apply)
40. Tobacco (amt) / 40a. Intervention
40b. Status stopped Quit date: mm/dd/yy decrease from ______to ______no change
41. Alcohol (amt) / 41a. Intervention
41b. Status stopped Quit date: mm/dd/yy decrease from ______to ______no change
42. Drug use (amt) / 42a. Intervention
42b. Status stopped Quit date: mm/dd/yy decrease from ______to ______no change
43. Prescription/OTC drugs / 43a. Intervention
43b. Status stopped Quit date: mm/dd/yy decrease from ______to ______no change
44. Other Substances (list) / 45. Interventions (narrative notes)
46. Change in readiness to quit
section VI – Psychosocial / Encounter notes
47. Domestic Violence / Rape
48. Unsafe home life/Afraid
49. Partner humiliates, shames, put-downs
50. Unsafe neighborhood
51. Homeless Currently In the last 3 months
52. lives alone No telephone
53. Transportation difficulties Childcare issues Other barriers
54. Perceived stress level High, Medium,
55. Perceived support level Enough Not enough
56. father of baby NOT involved
57. No family support nearby Who can you count on for help? Name:
58. Inadequate income to meet basic needs
a. Food b. Housing c. Clothing d. Car Seat e. Crib f. Other
59. mental Health Status
a. Depressed b. Suicidal ideation c. Suicidal w/ plan d. Other
Intervention:
60. Major life changes:
a. Employment change b. Divorce c. Incarceration d. Child(ren) removed from home e. Death of a family member
f. Homeless g. Recent miscarriage h. Other:
61. What do you do to deal with your problems?
62. What worries you the most?
63. What would you like to learn more about?
64. What would you like help with at this time?
How the baby is growing Labor and delivery Getting health care for you and you baby Managing stress Nutrition during pregnancy Breastfeeding Effects of alcohol on the baby Caring for your newborn
Family Planning/birth control How to stop smoking Managing the discomforts of pregnancy
Other (describe)
section VIi - INDIVIDUALIZED CARE PLAN REVIEW
PROBLEM / GOALS / PLAN
section viiI - NARATIVE NOTES
SECTION iX - Referrals
Date / Referral / Date / Referral / Date / Referral
Adoption / Food/Clothing Pantry / Rent / Utility Assistance
Alcohol / Drug Abuse Services / Human Services / Shelter, Homeless/ violence
Education / GED / Lactation consultant / Social Services
Child Birth Education / Medicaid / Smoking Cessation
DFC / Food Stamps/ TANF / Mental Health / Township trustee
Domestic Violence Program / Nutritionist / FNP / Transportation
Employment / Prenatal Care / WIC
Family Support/ parenting / Other/ / Other/
sECTION X - EDUCation
Date / Education Topic / Date / Education Topic / Date / Education Topic
Breastfeeding / Drug/alcohol cessation / Preterm Labor
Community Resources / Lessons Learned / Smoking cessation
Coping Skills / Normal discomforts / Secondhand smoke
Dental health / Nutrition / std/ signs of infection
Domestic Violence prevent / Prenatal Care / Vitamins/ Folic acid / iron
HIV risks/testing / Prenatal weight gain / Warning signs of pregnancy
Financial Planning / Other/ / Other/
First Encounter / Second Encounter
Signature – Staff Completing Assessment / Date / Signature – Staff Completing Assessment / Date
signature – Qualified Health Professional / Date
(If different from above) / signature – Qualified Health Professional / Date
(If different from above)

November 1, 2010 2