Montana Child Home Visit
Contents
1. sleepiRest DD Assistwith developing plan to address nightwakening sleepirest Link inforre benefits of sleep routines constant bed time sleepirest ______ Assistto develop sleep routine Activitwexercise Linkwithinfore lowandnocostplaymaterials ActivitExercise Link with info re importance of appropriate play materials activities and physical activi IT Activitexercise SS Linkwith info re interpreting infant cues LT Activitwexercise HOME evaluation Activitwexercise INGART Teaching assessment ActivitwExercise Medical referral Notes checklist Modify Add The Select Care Plan window allows you to select which care plans that you would like to add to the grid Put a checkmark in the Add column for which of the care plans you would like to add when finished click Add Care Plans amp Close ml Adult SMITH JANE 0170171976 33 Medical Record 2 Encounters HRPIO Intake HRPIO Outcome LSP Care Plan 5 0 A I P Assessment Tools Progress Notes narrative Progress Notes Checklist POES SSE E eS ___m Date Diagnosis S o p 02 05 2009 Nutrition Prenatal Care Plan p 02 05 2009 Nutrition Prenatal Date 02 05 2009 Elimination Prena 02 05 2009 02 05 2009 Elimination Prena fC Diagnosis SW Elimination Prenatal 1l Related To Max 254 characters py AJ H T D ie RL a HD sd Intervention CT SSC Link with info re when to access2. 1812 Encounters HRIIO Intake HRIIO Outcome LSP Care Plan S 0 ALP Assessment Tools Progress Notes narrative Progress Notes checklist Intake Date Completed By County Reservation Case 14 F Infant of a PHHV Client Mother seen in PHV during pregnancy In Utero Exposure to Alcohol Has an establisehd condition with a high probability A of resulting developmental delay even if the delay T Yes T No T Child or youth has or is at increased risk does not currently exist such as Birth Wt Lb Oz Grams for chronic physical developmental a E oe a behavioral or emotional conditions as Genetic disorders evidenced by M Inborn errors of metabolism Memo Gestational Aye Low or very low birth weight Documented child abuse or neglect Infectious disease Memo APGAR Foster care replacement F Neurological disorders Memo L 7 5 oe T Exposure to alcohol substance use or abuse rc T Memo 1 Min 5 Min prenatally in home or place of residence and or SUD D Breastfed second hand smoke T Visualfauditory impairments Memo T Breasted BottleFed J Both Regular use of medication prescribed by a doctor excluding vitmains T Severe attatchment disorders Memo Primary Health Care Provider Identified Yes T No Documented need for T Therapeutic services i e physical speech audiology occupational mental health nutrition home health or home nursing Homeless or substandard
3. Square boxes in this manual surround the key that you are to press on your keyboard As an example when you read press the enter key on your keyboard ENTER The word TYPE is followed by bracketed instructions of what to type into a field Note For Technical Support email helodesk hdis org Navigation Whenever you see one Os click the left side of your mouse once Whenever you see two CYS click the left side of your mouse twice Navigation Keys For Entering Information Or ENTER to move to next field Or to go back one field Editing Keys Backspace deletes one character left of cursor deletes one character inserting amp overwriting modes When you see a pull down field click the arrow to the right to view all your choices Starting HDIS Start Programs Health District Info Systems HDIS Health District Information System Menu Bar Health District Information System Management Services Environmental Health Community and Public Health Services Wital Statistics Maintenance About Exit HDIS Health District Information System L has several different modules designed to p assist your health district in its day to day operations The Home Visits module is a great addition to these modules and simplifies your record keeping billing and information management needs Community and Public Health Services Home Visits X Health District Information System Management Servi
4. buttons are clicked the above select Age form will appear for you to select the proper Age for the client 17 Progress Notes Narrative Optional Progress Notes Narrative Re SorntDates Delete Blank Progress Note Add Progress Note Zoom Print Modify Add To enter your narrative progress notes on the client right click the Add Progress Note button Click to open the print window Modify Add Click to modify a progress note record Click to open the progress note zoom window 18 W Child 14 Medical Record 1037 Encounters HRIlO Intake HRIIO Qutcome LSP Care Plan 5 0 A I P Assessment Tools Progress Notes narrative Progress Notes checklist S Progress Notes Progress Note Previous Progress Note Next Progress Note gi Spell Check Close Re Sort Dates Delete Blank Progress Note Add Progress Note Zoom Print Modify Add Click the Zoom button to navigate and enter your progress notes 19 Progress Notes Checklist Optional Progress Notes Checklist W Child 1 Medical Record 1037 Encounters HRIIO Intake HRIIO Outcome LSP Care Plan S OALP Assessment Tools Progress Notes narrative Progress Notes checklist Progress Notes checklist Screening Date F2 ASSESS F3 PLAN F4 MONITOR F5 REFER F6 EDUCATION Date of visit issue FocusArea TT tervention Notes aa H HO H a Re Sort tos Add F
5. T IC T Medicaid T No Referrals Made T Other Memo Print Modify Ada LSP Optional Medical Record 1037 Encounters HRIO Intake HRIIO Qutcome LSP Care Plan 5 0 A 1 P Assessment Tools Progress Notes narrative Progress Notes checklist Child s Last Name Child s First Name Date of Birth Individual Number Family Record Number ki 1037 587 Guardian s Last Name Guardian s First Name Date of LSP Date of Next LSP ga Initial Ongoing Closing 4 Ha MA E SC Home Visitor Agency Program T CUYAHOGA x 0 0 0 0 0 0 0 0 0 0 0 0 Medical Codes 0 0 Re Sort Dates Delete LSP Add LSP gt Zoom Print Modify Add The LSP tab is for entering your Life Skills Progression form for your client To enter the scores click the Zoom button Field Button Previous LSP Click to navigate to the previous LSP Next LSP Click to navigate to the next LSP Delete LSP Right click to delete the LSP form Add LSP Right click to add a LSP form Click to open the Zoom screen 10 Click to open the Print window Modify Add Click to modify add a LSP record m Child Medical Record 1037 Encounters HRIIO Intake HRIIO Outcome LSP Care Plan 5 0 A 1 P Assessment Tools Progress Notes narrative Progress Notes checklist Child s Last Name Child s First Name Date of Birth Individual Number Family Record Number kd 1037 587 The Life Skills Progressio
6. To begin entering encounters click the Modify Add button W Child ff Medical Record 1037 Encounters HRIlO Intake HRIIO Outcome LSP Care Plan S OALP Assessment Tools Progress Notes narrative Progress Notes checklist Program Setting Billable time ICD9 code CPTcode L rr ee IN eS ey es rr I ee O es Re Sort Dates Delete Encounter Add Encounter Zoom Print Modify Add Close Right click the Add Encounter button Once you have clicked the Add button you do not have to click it again to add the information a Encounter Zoom Date of Entry Date of Service Nurse Outreach Worker 07 22 2009 l C7 Program Setting Activity Billable Time ICDS CPT Code Non Billable Time Location of PHHV Face to Face Visit Travel Time Vehicle Mileage Total Time U Return Visit t i Previous Encounter Next Encounter Add to Dailys Close When the Add Encounter button is clicked the above Zoom screen appears for you to enter the encounter Field Button 6 Loc of PHHV Face to Face Choose the location of the face to face visit with the client Visit mandatory field Enter the return visit date optional HRIIO Intake HRPIO Intake ff Medical Record 1812 Encounters HRIIO Intake HRIIO Qutcome LSP Care Plan 5 0 A P Assessment Tools Progress Notes narrative Progress Notes checklist Intake Date Completed By County Reserv
7. Child LSP Child List HRIIO Clients Caseload Community Service Involvement Report Export LSFJHRPIO HRIIO Data HRIIO Intake ARIO Outcome HRPIO Intake HRPIO Outcome LSP Improvement Score Sheet Mailing Labels to Household By Encounters Referred By Return Visit Report State Reports To Be Billed A 4 KS KN S m User Defined Basar i Paro The Home Visits program has a set of pre defined reports to choose from Each reported will ask for From date and To date HRIIO Intake Report Options From HAIG Intake Date To HRI Intake Date if lig Employee L f Preview C Printer Filters Ok Close You may also preview the report before printing Also you have the ability to use filters to build a query 23 Reports Description Description CC Child By Nurse By Setting Generates a List of Clients and their Billable Non Billable Non Billable Travel Billable Travel times Time Child List HRPIO Clients Generates a list of HRPIO clients LSP Clients List LSP Clients HRPIO Outcome Vs Intake Measures outcomes for HRPIO risk factors Generates a caseload of clients by employee and program Community Service Counts Community Service being used Involvement Export LSP HRPIO HRIIO Used by Gallatin County for research purposes Data HRPIO Intake Generates your HRPIO Intake forms in bulk HRPIO Outcome Generates your HRPIO Outcome forms in bulk LSP Improvement Score Generates the L
8. medical assistance R T BI L T aas eR F2 Resolved F5 Intervention Completed F3 Closed F6 Barriers to Completion Previous Next Close F4 Intervention Ongoing F7 Client Refusal Delete Plan Row Add Care Plan Row gt Add Master Care Plan S 0 A 1 P Optional After you have added the care plans click Zoom to navigate through each care plan to enter the client s information 13 ff Medical Record 1037 ncoun ters HRIlO Intake HRIIO Outcome LSP Cars Pian S O AILP Assessment Tools Progress Notesfnarrativ Progress Notes checklist a rogre g Date Staff Subjective Objective Assessment Intervention Add SOAP Row Print _ Modity Add _ Modity Add The S O A I P tab is for entering your S O A I P notes for your client To add a row right click the Add S O A I P Row button Description Right click to put the dates in chronological order Right click to delete any blank rows in the grid Right click to add a S O A I P note Click to open the S O A I P zoom window Print Click to open the print window Pint S Modify Add Click to modify or add a S O A I P record 14 Intake Date lis Staff Subjective Assessment Intervention Previous SOAP Next S O API Spell Check Close Enter your S O A I P notes and click the close button To navigate through your notes use the Previous and Next buttons You also have to ab
9. Home Visits Child User s Manual Home Visits Child Health District Information System HDIS Windows Ver 5 3 Copyright 1998 by CHC Software Inc All Rights Reserved CHC Software Inc Health District Information Systems helpdesk hdis org Table of Contents INIKOQUCNO Nam 1 ADOUL INIS MANUA cirar AA 1 IAM ICON AA AA AA AA AA 2 Entering a Child RECOV a AN NAAN 4 ala AA A AE 4 AAO T 1 AA AA 7 ARIO OQUICOME ANNA AA 9 LSP ODUONAl AA AA 10 Care Plan Optional cccccccssecensecssecenseceseeensesenseenseseasesenees 12 S O A P OpU0Na Nima a AA 13 NATI dl Ke o KA AA PAA 16 Progress Notes Narrative Optional ccsssessssessseeees 18 Progress Notes Checklist Optional ccsseesseeeees 20 PEE 15 e TT 22 REDOT TTT 23 Maintenance Add Delete Modify Tables sscsssesseeneeeens 24 Introduction This program is designed to assist you in organizing a systematic approach to entering your High Risk Child visits and provides accurate up to date records within your health district Please review the manual carefully to obtain the maximum benefits Little or no prior computer experience is necessary to operate this program About This Manual HDIS is simple to use The maximum benefit with the least time spent will be obtained if you start at the first page of this manual and follow the directions exactly as you enter the first record in your computer
10. SP Improvement Score Sheet sheet Mailing Labels to Household Generates mailing labels by encounters By Encounters Referred By Generates a count report of referrals Return Visit Reports Generates a return visit report for your clients Grant 2006 Grant 2007 Quarterly Report Visits Generates a to be billed report for your Child clients by date Date of Entry of entry To Be Billed Child By Generates a to be billed report for your Child clients by date Date of Service of entry Maintenance Add Delete Modify Tables 24 i2 Maintenance Health District Information System Home visit Reports Browse ListlExport Count Graph Moines eg Return Add Delete ModiFy Tables Field Names General Profile Printer Setup Tables Adult Child 450 Information LSF Table Never Initiated Breastfeeding Reasons Tables Follow the Child Tables Household amp Client Details K L Tables Encounters K Care Plan High Risk Children Care Plan K K vee Supplement or Not Breastfeeding Reasons Tables Cascade County 1 Tables Gallatin County E Tables Lewis amp Clark Tables Missoula Tables Yellowstone County The maintenance menu contains a list of the tables that you can modify for your program For Child tables select Tables Child under the Maintenance Menu where you can add or modify your dropdown selections 25 al Add Delete Modify Close Add FOOD
11. STAMPS HELPING HANDS HMHE JOB AND FAMILY SERVICES Delete F MENTAL HEALTH SERVICES OPPORTUNITY INCORPORATED JOTHER PLANINED PARENTHOOD SALVATION ARMY ST VINCENT S TANE BITE The above is an example of what the Maintenance tables will look like Field Button Enter the name Closes the table Add Adds a row to the table Deletes the row Prints the table 26 CHC Software Inc Health District Information Systems helpdesk hdis org CHC Software Inc Health District Information Systems helpdesk hdis org
12. ation Case if R Has an establisehd condition with a high probability of resulting developmental delay even ifthe delay a 5 i OS No gat does not currently exist such as Birth Wt Lb Oz Grams or chronic physical developmental m Ge CU behavioral or emotional conditions as Convert to Grams evidenced by Gestational Age Low or very low birth weight Documented child abuse or neglect Mother seen in PHV during pregnancy E APGAR Foster care replacement g E Exposure to alcohol substance use or abuse 1 Min 5 Min prenatally in home or place of residence and or Breastfed second hand smoke y Ki y Regular use of medication prescribed by a doctor Primary Health Care Provider Identified excluding vitmains B e Documented need for audiology occupational mental health nutrition home health or home nursing Parent s have children in DPHHS custody a R Homeless or substandard housing services needed ig S IG S education special instruction case management Risk Factors care coordination respite care needed Z E a wil Jana IEEE equipment and assistive technology devices and services as a high risk pregnant woman and or Ka L U a i 9 S s 2 S health care need as designated by an ICD9 CM code transportation adaptation or social services needed d Add Intake Outcome J To add a HRIIO Intake form right click the Add Intake Outcome button f WMedical Record
13. ces Environmental Health EE Maintenance About Exit Format Appointment Books Adult Travel Immunizations Childhood Immunizations Communicable Disease Insurance Claims Lead Clinic Nurse Employee Daily Works Sheets Parents As Teachers Tuberculosis Testing Latent and Active Home Visit Hea h District Information System Home Visit heports Browse lis Export Count Graph Maintenance Return Naa l Entering a Child Record Household Information Household Information Find ByName C ByDOB C ByAddress C ByStreetName CMR Find Street Street Apt Address Directions 15054 ROSEMARY AVE P O Box City BIG SKY State Zip Code Phone Date of Entry Contact Instructions MT 44092 1 440 963 7175 02 13 2009 Political Subdivision Household size Gross income Verified Revised Sliding Fee Week Month Year Calc By Week EF PY Calc Sliding Fee Hi Middle Suffix DOB Sex _ Relationship SS Race l ClientDetaits i TA 10 04 1980 F pi L Add Client paa pn a 7 Ct Comments I an a nG mana a UI UA HU o NN When you are ready to enter the Child portion of the Home Visit module click the on the client in the grid you wish to enter data for and then click the Child button All fields labeled in RED are MANDATORY Encounters ff Medical Record 1037 Date Nurse Program Setting 3D BillabletimelCD9code CPTcode e HT HT T H H H
14. housing services needed S J S Archive Yes No l Famiy support services i e family couseling and education special instruction case management care coordination respite care needed Parent s have children in DPHHS custody T Yes T No Risk Factors T Child 212 months of age who was born to a woman who received PHHY and or TCM services as a high risk pregnant woman and or T Child or youth is diagnosed with a special health care need as designated by an ICD9 CM code T Equipment and supplies i e durable medical equipment and assistive technology devices and services needed T Early intervention special education special transportation adaptation or social services needed Delete Intake Outcome Add Intake Outcome Print Modify Add Enter the information for the intake form All fields labeled in RED are MANDATORY HRIIO Outcome HRPIO Intake Medical Record 1812 Encounters HRIIO Intake HRIIO Outcome LSP Care Plan 5 0 A I P Assessment Tools Progress Notes narrative Progress Notes checklist Date of Client Discharge Completed By Li Weight for length lt 5 percentile or gt 95 Yes No T Unknown Specify Memo Developmental milestones WNL l Yes T No Specify Merna Immunizations current T Yes No T Unknown Total of PHHV visits Total of Face to Face visits Length of time breastfed Three or More Residences or Homeless Yes N
15. ility to perform a spell check on your notes with the Spell Check button 15 Assessment Tools ff Medical Record 1037 Encounters HRIIO Intake HRIIO Outcome LSP Care Plan SOAP Assessment Tools Progress Notes narrative Progress Notes checklist Age amp Stages Questionnaire Delete ASQSE Information Add ASQSE Information Delete Tool Add Tool Print Modify Add The Assessment Tools tab contains three different tools that you can enter information for They are the Ages and Stages Questionnaire ASQSE and Tools 16 W Child 14 Medical Record 1037 Encounters HRIIO Intake HRIIO Outcame LSP Care Plan S 0 ALP Assessment Tools Progress Notes narrative Progress Notes checklist Age amp Stages Questionnaire Date 595 Communication Cutoff Gross Motor Cutoff Fine Motor Cutoff Problem Solving Cutoff Personal Cuj aa A Sy A e es EO OOT TO ea m n OOOO OOO EO Select Age for Proper ASQ Form Today s age in months Y 4 Months C14 Months C 6 Months C 16 Months C 8 Months 18 Months C40 Months 20 Months C42Months 22 Months C 24 Months E Delete ASQSE Information Add ASQSE Information Delete Tool Add Tool C 27 Months C 30 Months C 33 Months C 36 Months C 42 Months C 48 Months C 54 Months C 60Months Print Modify Add When the Add ASQ Information or the Add ASQSE Information
16. n Number 36 Ur TO El NOT ENROLLED OR ATTENDING 2 5 DELAYS MEET El NO DELAYS ABOVE AVERAGE CRITERIA AVERAGE DEVELOPMENT FOR DEVELOPMENT FOR AA OR CA AA OR CA Comments mnn Previous Next Close Re Sort Dates Next LSt Delete LSP Add LSP gt Zoom Print Modify Add The Zoom screen allows you to navigate through each question of the Life Skills Progression form To enter the score simply click on one of the black numbers You may also enter your own comments for each question Click the Previous or Next buttons to go to advance through the question 11 Care Plan Optional Care Plan ff Medical Record 1037 Encounters HRIIO Intake HRIIO Outcome LSP Care Plan 5 0 4 1 P Assessment Tools Progress Notes narrative Progress Notes checklist Date Diagnosis Related to F2 Resolved F3 Closed F4 Intervention Ongoing F5 Intervention Completed F6 Barriers to Completion F7 Client Refusal Delete Care Plan Row Add Care Plan Row Add Master Care Plan Zoom Print Modify Add To enter a Care Plan right click the Add Master Care Plan button HDIS has preloaded care plans already in the system but you can also create your own care plans under the Maintenance Menu Field Button Delete Care Plan Right click to delete the care plan Add Care Plan Row Right click to add a single care plan row 12 al Child Encounte
17. o T Unknown Infant s Primary Caregiver Screened with DV ACOG Tool during first year of life l Yes T No Parent s changes since intake in SMOKING HABITS NoChange Increase Decrease UNK SUBSTANCE ABUSE No Change Increase Decrease UNK ALCOHOL USE NoChange Increase Decrease UNK gt Number of emergency room visits Number of ear infections ma Number of calls reports made by PHHV for suspected child abuse and neglect pee Depression Screen Score pasa Diagnosed with a special health care need congenital anomaloies medical risk factors ICD9 DX aaa Referrals to child protective services Specify Mema Primary health care provider identified Yes T No T Unknown Medicaid l Yes No NotEligible Unknown WIC Yes No T NotEligible Unknown Early Intervention l Yes T No T Unknown Specialty Clinic l Yes T No T Unknown Enter the information for the Outcome form All fields labeled in RED are MANDATORY Exited PHHV project Lostto care T Child in out of home placement Child deceased Memo T Moved Refused T Transferred l Reclassified as child 12 months T Other Memo Referrals Made by PHHV to Community Service F MTUPP Quitline T Other Tobacco Cessation Resources Substance Abuse Cessation Resources T Domestic Violence Resources T Mental Health or Support Services T Resources to Obtain Housing T Food Resources Other than WIC
18. orm te En The Progress Notes Checklist allows you to enter pre created forms for the clients To add on of these forms enter the screening date and click the Add Form button wee Medical Record 1037 Encounters HRIIO intake HRIIO Outcome LSP Care Plan S 0 ALP Assessment Tools Progress Notes narrative Progress Notes checklist Progress Notes checklist Screening Date 02102009 F2 ASSESS F3 PLAN F4 MONITOR FS REFER F6 EDUCATION F2 ASSESS F3 PLAN F4 MONITOR F5 REFER F6 EDUCATION C a T Gallatin County Select Sereening Form Newborn Nuitrition Progress Notes checklist C Pediatric Progress Notes 0 6 Months C Pediatric Progress Notes 6 months 1 year C Pediatric Progress Notes 1 year 4 years C PostpartumiNewborn Assessment C Social Worker Progress Notes checklist Re sortDates Add Form Delete Emp Z00 Print Modi add Select the form that you wish to add to the grid and click the Add amp Close button 20 S Child f Medical Record 1037 Encounters HRIIO Intake HRIIO Outcome LSP Care Plan 0 A 1 P Assessment Tools Progress Notes narrative Progress Notes checklist W Progress Note checklist Date of Visit Home Visitor 0211 0 2009 F2 ASSESS F3 PLAN F4 MONITOR F5 REFER F6 EDUCATION Issue Focus Area Intervention 1 NUTRITI MOTHER S DIET Notes Gi Spell Check x Choices Add to Notes Next Previous x Cl
19. ose Re Sort Dates Add Form Delete Empty Rows Print Modify Add After the selected form has been added to the grid you can scroll through each issue by using the Zoom button 21 Print Button Print f Age amp Stages Questionnaire L Ages amp Stages Social Emotional Questionnaire l Care Plan f HRIIG Gutcome Form f HRIl0 Intake Form LSP Cumulative Scores t LSP Form t Specific Progress Note C Specific Staff Progress Notes L Specific 5 0 A P 7 SOALP Y Tools CU Encounters f Preview C Print Field Button Ages amp Stages Questionnaire Prints the Ages amp Stages Questionnaire Ages amp Stages Social Prints the Ages amp Stages Social Emotional Questionnaire Emotional Questionnaire Prints the care plan Prints the intake form Prints the LSP form Note you have positioned to S ic S O ic S O SP Cumulative Scores Prints the cumulative scores LSP form pecific S O A I P Prints a specific S O A I P note L L Progress Notes Prints the progress notes S S Prints the outcome form Prints a list of assessment tool tests and scores for the client K 22 Reports Reports Health District Information System Home visit Penne Browse ListlExport Count Graph Maintenance Return Adult K E Child By Nurse By Setting Billable Mon Billable Travel Time Child By LSP Date List LSP Clients Adult LSP Child By Next LSP Date List LSP Clients
20. rs H Date pi ai ae yt y E NE R H Eo Eo J a Boo Eo CT A eT E Delete Care Pla T wrk ila 45 1 Nw HW AIT E Select Care Plans Add Diagnosis intervention S O T Nutrition o Linkwith info re feeding methods and positioning appropriate amounts andioy Nutrition Refernutrition programs Nutrition Refer and assistto access dietician LI Nutrition Monitor neigntweiaht LT Nutrition Refer to food resources Nutrition Unki info re infant stimulation Nutrition Link with info re feeding cuesifeeding interaction LT Nutrition Link with info to modify feeding to adapt to special health care needs LT Nutrition Link with info rezrisks associated with sleeping with bottle Nutrition Link with info re weaning infant from bottle Elimination Refer and assistto access medical evaluation LI Elimination Linkwithinfore changes in normal functioning S Elimination Link with info re toilet training expectations Elimination Sleep Rest Monitor sleep pattems sleepRest Assist to develop sleep routine bed time and link with info re benefits of sleep routin SleewRest sf Asistto develop plan to develop optimal sleep environment steepRest Linkwithinfore sleepposition S sleenRest DD assistto develop and implement plan to adaptto special health care needs sleepirest Linkwithinfore daytimesleep
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