Healthy Start Encounter Form
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1Healthy Start Encounter Form
A. Client Demographic Information
1. Client ID
2. Medicaid ID
3. Last Name
Suffix
First Name
Middle Initial
4. Mailing Address (no. and street)
5. Zip Code
6. County
7a. Date of Birth
7b. DOB
8
9.
10.
11.
12.
mo
day
year
Verif.
Sex
Race
Ethnicity
Family ID
Relationship
13. Servicing Unit
14. Service Date
a. Dist
b. Area c. Unit
17. Svc Loc
mo
day
year
15. Special Group
16. Program Component (Check one only):
22
26
27
30
31
32
B. Service Codes
SVC.
Position
ONGOING CARE
Code
Svc.
Position
Number
INITIAL CONTACT
COORDINATION
Code
Number
# Svcs.
# Svcs.
Attempt to Contact
3103
Attempt to Contact
3303
*
Care Coordination Face to Face
Needs Tracking Only
3101
1
3320
Care Coordination Tracking or not Face-to-Face
*
Participant Needs Assessment
3102
1
3321
Declines Services
3110
1
Initial Family Support Plan Meeting
3322
No Further Services Needed
3111
1
Update Family Support Plan
3323
Receiving or Will Receive
3112
1
Declines Services
3310
1
Care Coord. from CMS/Early Steps
No Further Services Needed
3311
1
Receiving or Will Receive
3113
1
Receiving or Will Receiving
3312
Care Coord. from Another
Care Coordination From CMS/Early Steps
1
Provider, not CMS/Early Steps
Receiving or Will Receive
3313
1
Unable to Locate
3114
1
Care Coordination from another
Unable to Complete Initial Contact
3119
1
Provider, not CMS/Early Steps
Initial Contact Service Units
3115
Unable to Locate
3314
1
Ineligible for Services
3315
Transition to Interconceptional Care
3324
1
*
ONGOING CARE COORDINATION DETAILS for 3320 and 3321
INITIAL ASSESSMENT
Svc.
Position
Method of Contact
Face-to-Face
Home Visit
Code
Number
# Svcs.
Attempt to Contact
3203
Plan of Care Evaluated
Yes
No
Needs Tracking Only
3201
1
Plan Ongoing Care Coordination
3202
1
Plan of Care Changed
Yes
No
Declines Services
3210
1
Education Provided
circle all that apply
:
No Further Services Needed
3211
1
(
)
Receiving or Will Receive
3212
1
Baby Spacing/Family Planning
Nutrition
Care Coordination from CMS/EIP
Receiving or Will Receive
3213
1
Breastfeeding
Parenting
Care Coordination from Another
Provider, not CMS/EIP
Childbirth
Pre-term Labor Danger Signs
Unable to Locate
3214
1
Unable to Complete Initial Assessment
3219
1
Immunizations
Shaken Baby Prevention
Initial Assessment Service Units
3215
SIDS Risk Reduction
Other
OTHER HEALTHY START SERVICES
Svc.
Position
REFERRAL CODES
Tobacco Use (Circle one below):
Code
Number
# Svcs.
Referral Made
In Error
Nutrition Assessment/Counseling
4501
Receiving Services
Stopped Services
Services Completed
No Rescources Available
Psychosocial Counseling
8002
Unknown
Client Did Not Follow-up
Patient Declined
Parenting Support and Education
8004
Alcohol Use (Circle one below):
Referral Made
In Error
Childbirth Education and Support
8006
Receiving Services
Stopped Services
Services Completed
No Rescources Available
Breastfeeding Education and Support
8008
Unknown
Client Did Not Follow-up
Patient Declined
Tobacco Education and Smoking
8026
Substance Use: (Circle on below):
Cessation Counseling
Referral Made
In Error
Receiving Services
Stopped Services
Interconceptional Education and Counseling
8013
Services Completed
No Resources Available
Unknown
Client Did Not Follow-up
Patient Declined
Distribution: White=data entry; Yellow=file; Pink=billing
.
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Parent category: Medical