Postpartum Combined Assessment & Individualized Care Plan (Icp) Form Page 2

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Patient Identification
2
HEALTH EDUCATION ASSESSMENT
ICP Interventions
Info
F/U
R
8. Do you have questions/concerns about your................ 8.
Encouraged to attend infant care/parenting classes.
infant care/parenting skills?
Y
N
Referral:__________________________________________
___________________________________________
Ecd______________________________________________
9. Current health status:.................................................... 9.
Ecd re: health maintenance (include Pap, Brst exams) ............
Medical problems:
Y
N______________________
Referral:_______________________________________
Postpartum exam:
Y
N______________________
_________________________________________________
Medication:
Y
N___________________________
_________________________________________________
Prenatal vitamins:
Y
N Other:________________
_________________________________________________
10. Any difficulties with self care, physical changes or .... 10.
Ecd re: rest, exercise, personal hygiene, breast care
........
discomfort?
Y
N___________________________
Ecd re: involution, sexual activity_____________________
____________________________________________
_________________________________________________
11. Birth control plan:
Y
N.....................................
11.
Fwd STT HE 95-97 Family Planning Choices ....................
Method chosen:_______________________________
Ecd______________________________________________
____________________________________________
Referral:__________________________________________
12. Infant care:.................................................................... 12.
Discussed access to medical and emergency care. ...................
Medical provider:
Y
N___ _________________
Fwd STT HE 101-103 Infant Safety and Health .................
Medical insurance:
Y
N_____________________
Ecd STT HE HO-S, T
First well-baby exam:
Y
N___________________
Discussed well-child exams, immunizations. .....................
Any questions about infant’s health?
Y
N
Ecd STT HE HO-U
.....................
___________________________________________
Referral:___________________________________________
Feeding method:_______________________________
Fwd STT N 122-131 Breastfeeding
.......................
Feeding frequency/volume:______________________
Ecd STT N HO-AA, BB1-2, CC1-2, DD1-2, EE1-2
Problems:
Y
N __________________________
Fwd STT HE Infant Safety Seats
...............................
# wet diapers/24 hours:_________________________
Ecd_____________________________________________
Car seat in use:
Y
N________________________
Referral:__________________________________________
Health Education Problems/Needs
Plan (Developed in consultation with the patient.)
__________________________________________
______________________________________________________
__________________________________________
______________________________________________________
__________________________________________
______________________________________________________
__________________________________________
______________________________________________________
NUTRITION ASSESSMENT
ICP Interventions
13. Total pregnancy wt. gain_______lbs............................. 13.
Counseled on wt gain/loss
......................................
Current wt._______lbs. Plotted on grid.
Y
N
Ecd STT N HO-C
..........................................................
Total wt. loss______lbs.
Ecd_____________________________________________
Referral to RD:____________________________________
14. BP_______
14.
Notified medical provider.
........................................
Change since last visit:
Higher
Lower
Edema
Y
N Other:______________________
Reinforced medical recommendations.
...........................
15.
15.
Reviewed lab results.
......................................................
(Postpartum blood/urine obtained prior to this assessment.)
Hgb/Hct: _______Date:_____/_____/_____
Reinforced medical recommendations.
.............................
Abnormal blood/urine test results:________________
Fwd STT N 59-60 Anemia
.......................................
______________________Date:_____/_____/_____
Ecd STT N HO-L
......................................................
Referred to RD:____________________________________
16. Are you taking any of the following?.......................... 16.
Encouraged to continue prenatal vits. while breastfeeding.
Prenatal vitamins
Y
N Iron tablets
Y
N
_________________________________________________
Other vitamins/minerals
Y
N
_________________________________________________
Herbs
Y
N______________________________
________________________________________________
New medications
Y
N_____________________
_________________________________________________

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