FALLING THROUGH THE CRACKS: Appendix 2

Minnesota Pregnancy Assessment Form (Instructions below)

Patient's Name DOB

Patient's County of Residence

Please return to health plan (see training manual for address) or, if patient not enrolled in a health plan, to:
MN Department of Human Services
Children’s Health Section
P.O. Box 64202
St. Paul, MN 55164-0202

Patient's Address

Patient's MHCP ID # or Insurance # Patient's Phone #
Patient's Health Plan Name MHCP Provider ID # Provider's Name/Clinic Name

Provider's Phone #

Does this patient consider herself (check all that apply - optional):
Caucasian/White
Hispanic/Latino
Native American
African American/Black
Asian/Pacific Islander
Other: (please list) _____________________
EDC _______ / _______ / ________ e.g. MM / DD / YY
1st Visit
2nd Screen
Gestational Age
______ weeks
______ weeks
Date Screened
_____ / _____ / _____
_____ / _____ / _____
 
MM / DD / YY
MM / DD / YY
   
1st Visit
1.
Less than a 12th grade education
Y
N
2.
Currently unmarried
Y
N
3.
Age is < 18 or > 35 yrs
Y
N
4.
1st trimester pregnancy loss, any cause (3 or more)
Y
N
5.
2nd trimester pregnancy loss, any cause (2 or more)
Y
N
6.
Previous preterm labor with term delivery
Y
N
7.
Previous preterm delivery or low birthweight baby
Y
N
8.
Previous stillbirth
Y
N
9.
History of cone biopsy (laser or cold knife cone)
Y
N
10.
DES exposure
Y
N
11.
Any history of cervical cerclage or myomectomy
Y
N
12.
Last birth within 1 year
Y
N
13.
Significantly underweight or over weight during prepregnant period
Y
N
14.
During the last year prior to pregnancy has had gynecological infection (bacterial vaginosis, trichomonas, chlamydia, herpes, gonorrhea, syphilis)
Y
N
   
1st Visit
 
2nd Screen
(24-28 wks)
15.
Cervix dilated > 1 cm < 34 weeks this pregnancy
Y
N
 
Y
N
16.
Cervical shortening < 1 cm < 34 weeks this pregnancy
Y
N
 
Y
N
17.
Drank any beer, wine, wine coolers, or liquor since last menstrual period [1]
Y
N
 
Y
N
18.
Multiple gestation this pregnancy
Y
N
 
Y
N
19.
Diabetes mellitus
Y
N
 
Y
N
20.
Uterine anomaly
Y
N
 
Y
N
21.
Uterine irritability requiring medication, bed rest, hydration
Y
N
 
Y
N
22.
Abdominal surgery during this pregnancy
Y
N
 
Y
N
23.
Cocaine, marijuana, benzodiazepines, or street drug use this pregnancy [1]
Y
N
 
Y
N
24.
Poly/oligohydramnios this pregnancy
Y
N
 
Y
N
25.
Has been physically, sexually, or emotionally hurt by someone [1]
Y
N
 
Y
N
26.
Ever been or is currently being treated for an emotional disturbance
Y
N
 
Y
N
27.
Felt sad or down for more than 2 weeks in the past year [1]
Y
N
 
Y
N
28.
Initial prenatal visit > 20 weeks
Y
N
 
Y
N
29.
Febrile illness during this pregnancy
Y
N
 
Y
N
30.
Bleeding > 12 wks this pregnancy
Y
N
 
Y
N
31.
History of pyelonephritis
Y
N
 
Y
N
32.
Smoking more than 10 cigarettes per day this pregnancy
Y
N
 
Y
N
33.
Hypertension/preeclampsia
Y
N
 
Y
N
34.
Work: standing more than 4 hours/shift or heavy physical exertion
Y
N
 
Y
N
35.
Anemia (< 10 mg/dl) this pregnancy
Y
N
 
Y
N
36.
Inappropriate weight gain or loss this pregnancy
Y
N
 
Y
N
37.
Inadequate prenatal care (< 2 visits 2nd or 3rd trimester)
Y
N
 
Y
N
38.
During this pregnancy has had gynecological infection (bacterial vaginosis, trichomonas, chlamydia, herpes, gonorrhea, or syphilis)
Y
N
 
Y
N
39.
Has tested HIV positive
Y
N
 
Y
N
[1] Additional questions are recommended if yes          

Other risks:

At Risk Pregnancy
Y
N
Y
N

ENHANCED SERVICES: Check all that apply, and indicate person(s) / agencies that will be providing services.

At Risk Antepartum Mgm't. (Primary Provider: MD, CNM, DO) _______________________________________

Care Coordination ___________________________________________________________________________

Prenatal Health Education I ____________________________________________________________________

Prenatal Health Education II ____________________________________________________________________

Prenatal Nutrition Education ____________________________________________________________________

Postpartum Follow-up Home Visit _______________________________________________________________

REMINDER - Refer to WIC Services 1-800-657-3942

Signature of Primary Provider
1st Visit
Date
Signature of Primary Provider
2nd Screen
Date
Copy 1 - Patient Chart
Copy 2 - Payer (2nd Screen)
Copy 3 - Payer (1st Visit)
DHS-3294 (1-97)

HOW TO COMPLETE THIS FORM

This pregnancy assessment form is recommended for use with all pregnant women in Minnesota. This form is required for all persons who receive benefits from Minnesota Health Care Programs (MHCP), which include Medical Assistance (MA), General Assistance Medical Care (GAMC), MinnesotaCare, and MHCP patients enrolled in health plans (Prepaid Medical Assistance Program [PMAP], or MinnesotaCare enrollees). The first screening will be done at the first prenatal visit, and the second screening will be done at a prenatal visit around 24–28 weeks.

Identifying information:

1. Label or write in the identifying information. Include patient’s:name, date of birth, county of residence, address, MHCP ID # or insurance #, phone #, and patient’s health plan name (if applicable). Include provider’s:name and/or clinic name, MHCP Provider ID #, and phone #. If using a label, place a label on each of the three copies of the form.
2. Submit directly to the health plan for persons with PMAP or MinnesotaCare enrollees. Listed in the manual are the appropriate addresses/fax numbers for the Minnesota Department of Human Services and the participating health plans.

Completion of items:

1. Indicate the race/ethnic categories. Ask the patient with which group(s) she identifies (optional).
2. Complete the EDC using two digits for month, day, and year.
3. Report the number of weeks of gestational age at the first visit and at the second screening between 24–28 weeks.
4. List the actual dates of the screening visit using two digits for month, day and year.

Complete items 1–39 by marking an X in the appropriate box.
Other Risks: If you identify other risks, please write them in this box.

Is this an at risk pregnancy? Check “yes” if you determine this pregnancy to be at risk regardless of the number or type of risk factors.
Enhanced services for MHCP enrollees: Please document the services to be provided to MHCP enrollees to address identified risk factors. Check the boxes that apply, and list who will provide these services.
Signatures: Please sign and date the appropriate provider box for each screening.
WIC referral: Pregnant women who are on Medical Assistance and/or who are working and meet federal income guidelines can receive free nutritious food and additional nutrition counseling during their pregnancy. Please refer to WIC (1–800–657–3942).

What to do with the completed form: Retain two copies of the completed form for your patient’s record. Send one copy to the payer (health plan or DHS) for the first screen. Some health plans encourage providers to fax a copy to expedite payment and/or begin case management. After the second screen, send the second copy to the payer. If you are referring this patient to a community health service (CHS) agency, it may be appropriate to send a copy of the form with the referral.

RISK FACTOR DEFINITIONS
Preterm Less than 37 completed weeks gestation.   AB 2nd trimester Spontaneous or induced abortion between 12–19 weeks gestation.
Pregnancy loss Stillbirth, fetal demise.   Alcohol use Any use of alcohol during current pregnancy.
Hx preterm labor Spontaneous preterm labor after 20 weeks and before 37 completed weeks, with documented uterine contractions (4/20 or 8/60 minutes); plus ruptured membranes or intact membranes with cervical dilation of > 2 cm or intact membranes > 80% effacement; or intact membranes and cervical change during observation. Preterm labor or preterm delivery during any previous pregnancies whether or not it resulted in preterm or term birth.
  Underweight/overweight Prepregnancy weight < 90% or > 120% of Metropolitan Life Insurance Co. standards.
DES exposure Exposure to DES (diethylstibesterol) in utero.   Late prenatal care First prenatal visit at or after 20 weeks gestation.
Uterine anomaly Bicornate, T-shaped, septate uterus, etc.   Febrile illness Systemic illness with temperature of 101°F or greater such as influenza determined by thermometer reading on two or more occasions.
Uterine irritability Uterine contractions of five contractions in one hour perceived by patient or documented by provider without cervical change at < 34 weeks.
  Bleeding after 12th week Vaginal bleeding or spotting after 12 weeks gestation of any amount, duration, or frequency which is not
obviously due to cervical contact.
Surgery Any abdominal surgery performed at 18 weeks or more gestation or cervical cerclage at any time in this pregnancy.   Pyelonephritis One or more diagnosed episodes in past or current medical history.
Dilation (internal os) Cervical dilation of the internal os of 1 cm or more at less than 34 weeks gestation.   Work Work (paid or unpaid) which involves standing more than four hours per shift or heavy physical exertion.
Examples: nurses, cleaning staff, sales staff, babysitters, cashiers, laborers, etc.
Drug use Any street drug use during this pregnancy, e.g. speed, marijuana, cocaine, heroin (includes methadone), benzodiazepines.   Anemia Hematocrit < 31% or hemoglobin < 10 mg/dl.
AB 1st trimester More than three spontaneous or induced abortions at < 13 weeks gestation. Does not include ectopics.   Inappropriate weight gain Weight gain < 7 pounds at 22 weeks and/or weight loss > 5 pounds at any time in this pregnancy.
      Inadequate prenatal care Less than two visits per trimester in 2nd and 3rd trimester.
EXAMPLES OF ADDITIONAL RISK FACTORS
Medical
Thyroid disease
Type I diabetes
Type II diabetes
Renal disease
Heart disease
Blood borne disease
Autoimmune disease
Seizure disorder
Cervical cancer
Gestational diabetes
Psychiatric disorder
Exposure to chicken pox, rubella
History of DVT/
pulmonary embolus
Breast cancer
TORCH syndrome
OB History
Infertility
C-section
Grand multipara
Perinatal loss
Assisted reproductive
technology
Previa
Abruption
Poor Social Situation
Poverty
Personal or family history of abuse
Incarceration
Homelessness
Exposure to hazardous/toxic agents
Inadequate support system
Mental illness of family member
Child custody loss
Housing instability
Violence or substance abuse in the house or neighborhood
Nutrition
Diet deficient in one or more food groups
Excessive use of supplements
Hyperemesis
Food faddism
Pica
Eating disorder
Total vegetarianism
Barriers to Care
Child care problems
Cultural practices or beliefs about pregnancy
Language different than the provider
Scheduling issues
Transportation problems
Ambivalent, denying, or rejecting this pregnancy
Developmental disability
Number of children under five years of age in the home

Definition for Enhanced Services (See training manual for more complete definitions.)

Enhanced Services are a package of prenatal health services for MHCP enrollees who are determined to be at risk by this assessment.

At Risk Antepartum Managment: Provider who is primarily responsible for care of patient.

Care Coordination: Development, implementation, and ongoing evaluation of plan of care.

Prenatal Health Education I: Instruction on general information about pregnancy, warning signs of early labor, and education about other medical conditions.

Prenatal Health Education II: Education for patient who requires additional education related to at risk behaviors.

Prenatal Nutrition Education: Information and support for appropriate nutritional intake.

Postpartum Follow-up Home Visit: Visit planned within the first two weeks postpartum for assessment and education.

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