Children'S Special Health Services Flow Sheet Page 2
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3CHILDREN’S SPECIAL HEALTH SERVICES FLOW SHEET (DHHS 2809)
This flow sheet is designed to monitor children with special needs through adolescence. Health
problems which cannot be documented adequately with the code abbreviations require a SOAP or
Narrative note on the Notes (DHHS 2803). Record the letter “N” from the code in the appropriate box
on the Children’s Special Health Services Flow Sheet to reference information in the Notes.
1.-6.
NAME, NUMBER, ETC
In the blank space in the top left on the front, attach the
computer generated label or emboss the information
imprinted on the patient’s identification card or manually
record the patient’s name (last name, first name, and
middle initial), identification number, date of birth
(MM-DD-YYYY), race and ethnicity, gender, and county
of residence.
7.
ENGLISH SPEAKING
Check “Yes” or “No” as appropriate. If “No”, record
the language spoken.
8.
INTERPRETER
Check “Yes” or “No” as appropriate. If “Yes”,
record who is providing interpretation.
9.
ALLERGIES
List all patient’s allergies: food, drugs, insects,
environment. Record in red ink if possible.
10.
CLINIC TYPE
Check as appropriate.
11.
DATE/AGE
Enter the date of the assessment and age of the child
at the time of the visit at the top of each
successive column.
12.
INFORMANT/RELATIONSHIP Record informant’s relationship to the patient. As
appropriate, note if informant is not able to provide
needed information.
13.
CURRENT PROBLEM;
Record reason for the visit, including complaints or
COMPLAINT; PARENTAL
parental concerns. Use informant’s words if possible.
CONCERNS
Update at each visit. Record the following information
with updates as needed: Date and Age of Onset; Course
and Duration; Effect of Treatment; and Referral Source.
14.
IMMUNIZATION STATUS
Record current status of immunizations. Indicate need
REFERRAL/FOLLOW-UP
for immunizations or follow-up to determine status.
15.
CURRENT PROVIDER
Record the name of the physician/health care provider/
FOR WELL CHILD CARE/
medical home generally contacted. Record date of last
MEDICAL HOME
well visit.
16.
OTHER MEDICAL OR
Identify and record other medical or health issues affecting
HEALTH CARE PROBLEMS/
this patient and providers as indicated.
PROVIDERS
17.
CURRENT MEDICATIONS
Record all over the counter or prescription drugs that patient
takes on a regular basis.
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