Health Services Tracking Sheet Instructions (2-6 years) Policy Number and Last Update (03.02.06/01-2011)
Column 1 (M,C,I): Under the child's row number, enter an M if the child is enrolled in the Medicaid program; enter a C if the child is enrolled in the CHIP; or enter an I if the child has private health insurance. If the child has more than one coverage, enter the appropriate letters. If the child was enrolled in the program before enrollment in MHS, circle the appropriate latter. (This information will be needed for PIR.)
Column 2 (Name/Dates): Enter the child's name, with enrollment and departure dates below. If the child leaves the program and later re-enrolls, enter the second enrollment and departure date also.
Column 3 (DOB): Enter child's date of birth with full year, e.g. April 20, 2007 as 04-20-2007.
Column 4 (Physical): Enter a Y (yes) if the child has a current physical on file per licensing regulations. Enter an N (no) if the child does not meet this requirement. If N, this then becomes a priority service.
Column 5 (Well Child): After age 2, a child needs an exam annually. Enter the date of the last exam under "Last Date". Determine when the next exam is due and enter that date under "Next Due". If a child has a follow-up need (e.g. treatment) found at the last exam, circle the "FN" box in red. When the follow-up has begun, circle the "FB" box. When the follow-up is completed, circle the "FC" box.
Column 6 (Dental): An annual dental exam done by a dentist is required starting at age 2. An exam for children younger than 2 may be indicated when obvious signs of decay are present or a referral is made by the doctor at the time of the physical exam. The dentist may recommend an exam more often than annually. Enter information for the dental exam as described in the Well Child Exam instructions. Circle "PF" box when cleaning and fluoride is done as recommended.
Column 7 (HCT/HGB): A test for anemia is recommended annually. Track follow-up as described in Well Child Exam instructions.
Column 8 (Lead): Children living in high-risk environmental situations should be screened annually. Migrant children are considered high-risk. Track follow-up.
Column 9 (Vision/Hearing): Beginning at age 3, formal vision and at age 4, formal hearing testing occurs annually. A pure-tone audiometer must be used for the hearing test. Circle the appropriate box for P = pass; F = Fail; or R = Referral. If the child is unable to perform a test, note CNT under the screening date.
Column 10 (TB): Annual tuberculin testing by the MANTOUX method of high-risk children is recommended. Migrant children are considered high-risk. Circle the appropriate box for outcome N = Negative; P = Positive; or R = Referral. If the child has had at least one negative test, have the doctor determine if another is necessary. If not, have him/her write "Not Indicated" on the physical form.
Column 11 (Ht/Wt): Note date that initial height and weight is charted on the growth chart.
Column 12 (Health History): Note the date when child's initial or annual updated health history is taken. This may be done by the child's health care provider and a copy obtained for the child's file. If not, the program's HSC must interview the parent and complete the form in the Health Procedures manual.
Column 13 (Nutrition): Note the date when child's nutrition intake is taken. This may be done by WIC and a copy obtained for the child's file. If not, the program's HSC must interview the parent and complete the form in the Health Procedures manual. If the child is not enrolled in WIC, then the program's nutritionist does the nutrition assessment.
PAGE TWO (this form is used for both age groups)
Column 1 (Follow-up): List follow-up needs as tracked on other side of this sheet. Note date of written follow-up plan. (e.g. Dental treatment needed, plan 7-9-2002).
Column 2 (Progress): Briefly note progress made toward completing the written follow-up plan. (e.g. Dental appt. made. First treatment done 7/22/2002. Second treatment done, all complete 8/1/2002).
Column 3 (Doctor): Enter the name and phone number of the doctor the child's family uses while in Illinois.
Column 4 (Medicaid/Insurance): Enter the number from the child's Medicaid or insurance card.
Column 5 (Transition): Briefly note transition needs and dates of records' transition and to whom. (e.g. Overdue for well child exam, records sent to grantee for TX 10-25/2002, or Dental treatment incomplete, records sent to FL MHS program 9/29/2003, or Transitioned to Kinder, record forwarded to Lincoln school 8-20-2003.)
Column 6 (Records to Parents): Note date the parents were given the child's records before leaving. Remember to have parents sign that they received the records.