How to Complete Screens

PATIENT INSTRUCTIONS FOR COMPLETING THE PRENATAL RISK SCREENING INSTRUMENT

(pdf chart go here)

PROVIDER INSTRUCTIONS FOR COMPLETING THE PRENATAL RISK SCREENING INSTRUMENT

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Please note that the form is to be signed by the patient. Please review for completion prior to forwarding ALL screening forms (white and yellow copies) to the Healthy Start Risk Screening Office, Broward County Health Department, 2421 SW 6th Avenue, Fort Lauderdale, FL 33315.

FIRST STEP:

See instructions for on the back of the green copy (patient copy) of the form.
If the patient would like to participate in the screening process, the patient should complete questions 1-16, the patient information section and the consent statements with signature and date and the provider should complete the provider section.

Question 9: If the patient answers “yes”, make the appropriate referral based on Domestic Violence services available in your community.
Question 18: Use the BMI chart on the back of the yellow copy to determine the patients BMI score based on height and weight information. If the patient’s BMI score is less than 19.8 or greater than 35, check the box of the appropriate response.
Question 19: If the patient answered “no” to Question 15, provide a date and the date is less than 18 months before the current pregnancy, check yes. If the date the patient provided in Question 15 is greater than 18 months or the patient answered “yes” to Question 15, check “no”.
Question 20: Enter the trimester at which the patient had her first prenatal visit. If the patient entered prenatal care in the second trimester, check “2nd”.
Question 21: Check “yes” if the patient requires ongoing medical care and specify the condition or diagnosis

Complete the name of the Physician, Certified Nurse midwife, or Advanced Registered Nurse Practitioner providing the prenatal care. Also complete the provider I.D. (the number established by the county for each provider), phone number, and county for the prenatal healthcare office.

SECOND STEP:

Determine the patient’s Healthy Start screening score. Along side of the check boxes for individual risk factors are a subscripted number, which is the number of the Healthy Start points assigned to that risk item. Circle the corresponding check box and point value for risk factors based on responses to specific questions. Add the circled points. This total is the patient’s Healthy Start screening score and is important to evaluate Healthy Start and must be completed.
Refer the patient for participation in Healthy Start care coordination if (a) the prenatal screening is six or more, or (b) the patient is at risk for an adverse outcome based on factors other than score, including maternal illness, homelessness, domestic violence, HIV status, substance abuse, or other factors that Healthy Start care coordination and risk appropriate services might reduce. Check the appropriate box to indicate referral status. Discuss the Healthy Start screening score and status for care coordination with the patient. Sign and date the form.
Please note that the form is to be signed by the patient. Please review for completion prior to forwarding all screening forms (white and yellow copies) to the county health department in the county where screening occurred. Keep the pink copy in the patient’s medical record and give the patient the green copy. This documents compliance with s.383.14, F.S. The demographic data is important to evaluate Healthy Start and must be completed.

IF PATIENT DECLINES PARTICIPATION IN SCREENING:

If the Patient signs the decline statement under the patient information section of the form, ask the patient to fill in demographic information, and sign and date the form below the statement denoted with an asterisk* located just above the provider section. Except for provider identification information and signature, the remainder of the form is not completed. If the patient refuses to sign the form, write “patient refuses to sign” on the form. Assure the patient that she will continue to receive care.
Send the screening form white and yellow copies) to the Healthy Start Risk Screening Office, Broward County Health Department, 2421 SW 6th Avenue, Fort Lauderdale, FL 33315.

Mail completed forms to:

Healthy Start Risk Screening
Broward County Health Department
2421 SW 6th Avenue
Fort Lauderdale, FL 33315-2613

Prenatal Screening Cheat Sheet

Please remember:

Screen all pregnant patients upon their first prenatal exam
Encourage your patients to CONSENT to the Screen & Services, even if you do not think they will be eligible. Have each patient initial “Yes”, “Yes”, “Yes” at the bottom section and sign the form.
The scoring mechanism for the form is located underneath the risk factor. Only score those items that have a number under them. [example: (1)]. It is a good idea to discuss your patient’s score and eligibility.
Mail completed forms once per week, minimally. Do not let completed forms sit at your office.
Make sure your forms are absolutely complete. If anything is missing – it will be sent back to you!

Scoring Mechanism - Patient Section:

EN (Education No)	1 point
MN (Married No)	1 point
Client down, depressed or hopeless	1 point
RB (Race Black)	3 points
Client had a drink	1 point
Client smokes	1 point
1st Pregnancy	2 points
Baby < 5lbs, 8 ounces at birth	3 points
Baby not born alive	3 points
Baby born 3 weeks or more before due date	3 points
A < 18 (Age under 18)	1 point

Provider Section (Your section):

BMI < 19.8	1 point
BMI > 35.0	2 point
Pregnancy Interval < 18 months	1 point
Entering prenatal care in 2nd Trimester	1 point
Patient has ongoing medical care	2 points

Please place the patient’s score in the box stating “Healthy Start Screening Score.” You will invite her to participate based on a score of “6” or more. You may also invite her to participate if her score is under “6”, by checking “Invited to participate based on factors other than score.”