Form Instruments for Me Instruments for Me Instruments for Medical Staff

E-1

ATTACHMENT E:

INSTRUMENTS FOR MEDICAL STAFF

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Newborn’s Medical Record Audit

E-2

Staff Completed Newborn Items

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Attachment E-1

Newborn’s Medical Record Audit

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FEBRUARY 23, 2010 FORMAT
Readmit |__|
Initial |__|__|

DATE:

Form Approved
OMB No. xxxx-xxxx
Expiration Date xx-xx-xxxx

2 0
|__|__| |__|__| |__|__|__|__|

START TIME: |__|__| : |__|__| a.m. |__|
p.m. |__|

END TIME: |__|__| : |__|__|a.m. |__|
p.m. |__|

MOTHER’S ID# |__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|

2 0
MOTHER’S GPRA INTAKE DATE |__|__| |__|__| |__|__|__|__|
2 0
CHILD’S DATE OF BIRTH |__|__| |__|__| |__|__|__|__|
EVALUATION PHASE: Intake |__|

Delivery |__|

PERSON COMPLETING |_______________|

GRANT#

TI |__|__|__|__|__|__|

NEWBORN’S MEDICAL RECORD AUDIT
Please document the actual numbers of the information being requested below. Record the child’s ID on top of each column.
(Extra columns are provided for twins/multiple births.)
Complete if child born to mother while she is in treatment or if child is less than 3 months old at intake.
CHILD |__|__|
CHILD |__|__|
CHILD |__|__|
CHILD |__|__|
Apgar score
|__|__|
|__|__|
|__|__|
|__|__|
|__|__|.|__|

|__|__|.|__|

|__|__|.|__|

|__|__|.|__|

Head circumference

CM

Length at birth

CM

Birth weight

|__|__|.|__|__|

|__|__|.|__|__|

|__|__|.|__|__|

|__|__|.|__|__|

KG

KG

KG

KG

Gestational age

|__|__|.|__|__|
in weeks

Drug screen

IN

CM

|__|__|.|__|

|__|
|__|
|__|
|__|
|__|
|__|
|__|
|__|
|__|

CM

LB

_____________
_____________

CM

|__|__|.|__|

IN

NEGATIVE
COCAINE
METHADONE
OTHER OPIATES
MARIJUANA
METHAMPHETAMINE
ALCOHOL
NICOTINE
OTHER POSITIVE

IN

|__|
|__|
|__|
|__|
|__|
|__|
|__|
|__|
|__|

CM

LB

NEGATIVE
COCAINE
METHADONE
OTHER OPIATES
MARIJUANA
METHAMPHETAMINE
ALCOHOL
NICOTINE
OTHER POSITIVE

_____________
_____________

CM

|__|__|.|__|

IN

|__|__|.|__|__|
in weeks

IN

|__|
|__|
|__|
|__|
|__|
|__|
|__|
|__|
|__|

|__|__|.|__|

IN

CM

LB

|__|__|.|__|__|
in weeks
NEGATIVE
COCAINE
METHADONE
OTHER OPIATES
MARIJUANA
METHAMPHETAMINE
ALCOHOL
NICOTINE
OTHER POSITIVE

_____________
_____________

IN

|__|
|__|
|__|
|__|
|__|
|__|
|__|
|__|
|__|

IN

LB

|__|__|.|__|__|
in weeks
NEGATIVE
COCAINE
METHADONE
OTHER OPIATES
MARIJUANA
METHAMPHETAMINE
ALCOHOL
NICOTINE
OTHER POSITIVE

_____________
_____________

Not to be used without the written permission of Karen Allen, Ph.D.

Public reporting burden for this collection of information is estimated to average 5 minutes per response; including the time for reviewing
instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of
information. Send comments regarding this burden estimate or any other aspect of this collection of information to SAMHSA Reports Clearance
Officer, Room 7-1044, 1 Choke Cherry Road, Rockville, MD 20857. An agency may not conduct or sponsor, and a person is not required to
respond to a collection of information unless it displays a currently valid OMB control number. The control number for this project is 0930-0269.

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Attachment E-2

Staff Completed Newborn Items

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READMIT |__|
INITIALS |__|__|
DATE:

2 0
|__|__| |__|__| |__|__|__|__|

START TIME: |__|__| : |__|__| a.m. |__|
p.m. |__|

END TIME: |__|__| : |__|__|a.m. |__|
p.m. |__|

2 0
MOTHER’S ID# |__|__|__|__|__|__|__|__|__|__|__|__|__|__|__| MOTHER’S GPRA INTAKE DATE |__|__| |__|__| |__|__|__|__|
2 0
CHILD’S DATE OF BIRTH |__|__| |__|__| |__|__|__|__|

EVALUATION PHASE:

Intake |__|

Delivery |__|

GRANT# TI |__|__|__|__|__|__|

PERSON COMPLETING |_______________|

INTAKE: STAFF COMPLETED NEWBORN ITEMS

This tool should be completed by project staff for each child born to a woman in treatment or within 3 months of her intake date. Please
document the information requested below as specified in the Newborn’s medical record. If the requested information is not included in
the medical record, please select “Not specified”. Record the child’s ID on top of each column. (Project staff should complete one form
for each birth. Extra columns are provided for twins/multiple births.)
ITEM
CHILD ID |__|__|
CHILD ID |__|__|
CHILD ID|__|__|
1. Was this newborn born
Yes |__|
Yes |__|
Yes |__|
premature (less than 37
No |__|
No |__|
No |__|
weeks gestation)?
Not specified |__|
Not specified |__|
Not specified |__|
2.

Did this newborn have any Yes |__|
congenital anomalies or
No |__|
Not specified |__|
birth complications?

Yes |__|
No |__|
Not specified |__|

Yes |__|
No |__|
Not specified |__|

_________________________

_________________________

_________________________

_________________________

_________________________

_________________________

_________________________
Not specified |__|
N/A |__|
|__|__| month
Newborn Hospital
|__|__| day
Discharge Date/Time
|__|__|__|__| year
|__|__|: |__|__| time
AM |__| PM |__|
If newborn's length of stay Child needed care|__|
in hospital is greater than 3 Mother needed care |__|
Social service concern|__|
days, please specify why.
Other _______________ |__|
Not specified |__|
N/A |__|
Yes |__|
Was newborn admitted to
No |__|
NICU?
Not specified |__|

_________________________
Not specified |__|
N/A |__|
|__|__| month
|__|__| day
|__|__|__|__| year
|__|__|: |__|__| time
AM |__| PM |__|
Child needed care|__|
Mother needed care |__|
Social service concern|__|
Other _______________ |__|
Not specified |__|
N/A |__|
Yes |__|
No |__|
Not specified |__|

_________________________
Not specified |__|
N/A |__|
|__|__| month
|__|__| day
|__|__|__|__| year
|__|__|: |__|__| time
AM |__| PM |__|
Child needed care|__|
Mother needed care |__|
Social service concern|__|
Other _______________ |__|
Not specified |__|
N/A |__|
Yes |__|
No |__|
Not specified |__|

_________________________

_________________________

_________________________

a. If YES, please specify
why newborn was sent to
NICU.

_________________________

_________________________

_________________________

_________________________
Not specified |__|
N/A |__|

_________________________
Not specified |__|
N/A |__|

_________________________
Not specified |__|
N/A |__|

b. If YES, Newborn
Admission to NICU
Date/Time

|__|__| month
|__|__| day
|__|__|__|__| year
|__|__|: |__|__| time

|__|__| month
|__|__| day
|__|__|__|__| year
|__|__|: |__|__| time

|__|__| month
|__|__| day
|__|__|__|__| year
|__|__|: |__|__| time

a. If YES, please specify.

3.

4.

5.

E-6

6.

AM |__| PM |__|
N/A |__|

AM |__| PM |__|
N/A |__|

AM |__| PM |__|
N/A |__|

c. If YES, Newborn
Discharge from NICU
Date/Time

|__|__| month
|__|__| day
|__|__|__|__| year
|__|__|: |__|__| time
AM |__| PM |__|
N/A |__|

|__|__| month
|__|__| day
|__|__|__|__| year
|__|__|: |__|__| time
AM |__| PM |__|
N/A |__|

|__|__| month
|__|__| day
|__|__|__|__| year
|__|__|: |__|__| time
AM |__| PM |__|
N/A |__|

Was newborn diagnosed
with Neonatal Abstinence
Syndrome (NAS)?

Yes|__|
No|__|
Not specified|__|

Yes|__|
No|__|
Not specified|__|

Yes|__|
No|__|
Not specified|__|

a. If YES, is NAS due to
maternal substance use?

Yes|__|
No|__|
Not specified|__|
N/A |__|

Yes|__|
No|__|
Not specified|__|
N/A |__|

Yes|__|
No|__|
Not specified|__|
N/A |__|

b. If YES, was NAS
treated?

Yes|__|
No|__|
Not specified|__|
N/A |__|

Yes|__|
No|__|
Not specified|__|
N/A |__|

Yes|__|
No|__|
Not specified|__|
N/A |__|

_________________________

_________________________

_________________________

c. If YES, what treatments, _________________________
specifically for NAS, did the
newborn receive?
_________________________
Not specified |__|
N/A |__|

_________________________

_________________________

_________________________
Not specified |__|
N/A |__|

_________________________
Not specified |__|
N/A |__|