Postpartum Combined Assessment & Individualized Care Plan (Icp) Form
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1
2
3Patient Identification
Comprehensive Perinatal Services Program
POSTPARTUM COMBINED ASSESSMENT &
INDIVIDUALIZED CARE PLAN (ICP)
Date:_____/_____/_____
Weeks postpartum:_____
Delivery date:_____/_____/_____
Type:__________
Infant’s name:_________________________________
Sex:____
Birthweight:______________
Weeks gestation:_______
Live Birth: Y___N___ Major anomaly: Y___N___
Abbreviations: Ecd--educated Fwd--followed HE--Health Education HO---handout N--Nutrition P--Psychosocial STT--Steps to Take Y--Yes N--No
N/A--not apply
(Info, F/U, R: See Guidelines)
Info FU R
PSYCHOSOCIAL ASSESSMENT
___________________ICP Interventions____________________
1. Do you have any questions/concerns about your ......
1.
Educate to allay fears.
....................................
Ν Describe: _________________
delivery?
Y
Ecd_______________________________________________
_________________________________________
Encouraged to discuss concerns with provider.
Delivery complications?
Y
N Describe:________
Referral:___________________________________________
_____________________________________________
__________________________________________________
2. Do you feel comfortable about your relationship with
2.
Ecd_______________________________________________
your baby?
Y
N Any concerns?
Y
N
__________________________________________________
_________________________________________
__________________________________________________
How have others adjusted to your baby?
__________________________________________________
FOB:________________________________________
Referral:__________________________________________
Family:______________________________________
__________________________________________________
Friends:_______________________________________
__________________________________________________
Other:_________________________________________
__________________________________________________
3. Do you have concerns about?......................................
3.
Referral:___________________________________________
Finances
Y
N
Food/clothing
Y
N
Referral:___________________________________________
Living accommodations
Y
N Baby items
Y
N
_________________________________________________
Transportation
Y
N Child care
Y
N
Fwd STT P 28-34 Financial Concerns ...................................
4. Are you feeling?.........................................................
4.
Counseling referral:__________________________________
Lack of emotional support
Y
N
_________________________________________________
Overwhelmed
Y
N “Weepy” (PP Blues)
Y
N
Ecd______________________________________________
Sad, depressed
Y
N
_________________________________________________
Thoughts of harming self, baby, others
Y
N
_________________________________________________
Other___________________________________
_________________________________________________
5. Have you returned to work/school?
Y
N................ 5. ___________________________________________________
6. Perinatal substance use?
Y
N................................ 6.
Referred to Perin. Subst. Abuse Program.
........................
Changes in use?
Y
N Describe: _____________
Fwd STT HE 87-91 Drug & Alcohol Use ....................................
___________________________________________
Fwd STT P 65-68 Perinatal Substance Abuse .....................
Alcohol_____________________________________
Ecd per STT P HO-H
........................................................
Street Drugs_________________________________
Fwd STT HE 83 Secondhand Tobacco Smoke
.................
Tobacco____________________________________
Fwd STT HE 79-82 Tobacco Use
........................................
__________________________________________
Ecd per STT HE HO-Q ..........................................................
Prescription drugs ___________________________
__________________________________________________
7. Are you experiencing threats or abuse from your............ 7.
Fwd STT P 53-59Spousal/Partner Abuse .............................
partner? Emotional
Y
N
Physical
Y
N
Ecd per P HO-E, F
..............................................
Sexual
Y
N _______________________________
Referral:___________________________________________
_____________________________________________
___________________________________________________
Psychosocial Problems/Needs
Plan (Developed in consultation with the patient.)
__________________________________________
_______________________________________________________
__________________________________________
_____________________________________________________
__________________________________________
_______________________________________________________
__________________________________________
_______________________________________________________
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