MEDICAL-IN-CONFIDENCE HEALTH VISITOR COPY

27-30 Month Review IF THE CHILD IS MORE THAN 32 MONTHS OLD PLEASE USE AN 'UNSCHEDULED' FORM
SCHEDULED DATE OF ASSESSMENT: DATE ASSESSMENT COMPLETED:

CHI NO HB
GENDER
HEALTH VISITOR
TREATMENT CENTRE
GP
PLEASE PRINT CLEARLY IN BALL POINT PEN
Please check the information above and if appropriate, enter amendments below. Please also advise the GP of any changes.
Change of name to: Change of GP to:

Change of TC to: CHSP PS SIRS Change of Caseload HV No to :

Change of address to: Postcode:

Primary Additional Current

Carer present with child at review (Y) carer carer Other LAC Status

Ethnicity * Is English 1st language at home? (Y/N) * Bilingual/multilingual (Y/N) *

At risk TB * BCG Given *
TB Risk Status - Please indicate which countries the following people were born in: Child *
Parents/Carers (1) (2) *
Grandparents
(where

(1) (2) *

applicable)

(3) (4) *
Childsmile outcome 6-8 weeks * Registered with Dentist at 24 months * Attended Dentist in last 12 months *
Primary carer current smoker (Y/N) Child exposed to 2nd hand smoke (Y/N)

Concerns raised by carer, enter (R)

Feeding/Diet Growth/Weight Sleep Development Physical Health Other

Development outcome of assessment: N - No Concerns C - Concern newly suspected P - Concern/Disorder previously identified X - Assessment incomplete

Speech, Language
Social Emotional Behavioural Attention & Communication
Gross Motor Fine Motor Vision Hearing

Tools: - indicate all used during the review to support developmental assessment (see over for codes)

Physical examination: Height (cms) Weight (kg) Date measured

Future action: enter code if applicable P - Provide S - Signposted to D - Discuss with R - Request assistance from W - Refused

Parenting Speech & Community

GP Support Audiology Language Paediatrics CAMHS Childsmile

Smoking Early Financial Other

Cessation CHW Education Advice Services Social Work Physio/OT Services

(enter Y for all that apply)

Registered Other Proposed
Attends: Nursery Playgroup Childminder Childcare None Pre School Nursery

Summary: list any issues likely to be relevant to the child's ongoing health, development or well-being.
ENTER ISSUE STATUS
PLEASE PRINT CLEARLY Issue Status Read Code

(1)

(2)

(3)

(4)

Recall to HV in wks Appt - enter S, M, L Reason for recall

Health Plan Indicator (HPI)

* Updated HPI Support Needs Status
* Parental consent to share
information from this review
Summary comment

Practitioners involved in review GP

(enter Y for all that apply) HV Staff Nurse Nursery Nurse/FSW Other

Place of review
(enter Y for all that apply) Home Clinic GP Practice Other

Signature Print Name HV No

ver 1.1.6 141215

 CHILD HEALTH PROGRAMME – PRE-SCHOOL
Items marked with an * will be pre-printed with data, if already recorded on the system

Current LAC Status

0 Not currently looked after by local authority
1 Looked after at home
2 Looked after with friends/relatives (placed with friends or relatives who are not approved foster carers)
3 Looked after with foster carers (placed with approved foster carers provided by or purchased by the local authority
4 Looked after with prospective adopters
5 Looked after in other community placement (eg supported accommodation, hospital)
6 Looked after in residential care (any form of residential care eg local authority or voluntary children’s home or crisis care refuge)

Ethnicity Code List

This code list was developed for the 2011 census and is the agreed national NHS Scotland standard list.
Code 99 indicates that the individual was not asked, if they decline to answer code 98 should be used
Group A - White Group D - African
1A Scottish 4D African, African Scottish or African British
1B Other British 4Y Other African
1C Irish
1K Gypsy / Traveller Group E – Caribbean or Black
1L Polish 5C Caribbean, Caribbean Scottish or Caribbean British
1Z Other white ethnic group 5D Black, Black Scottish or Black British
5Y Other Caribbean or Black
Group B – Mixed or Multiple Ethnic Groups
2A Any mixed or multiple ethnic groups Group F - Other Ethnic Group
6A Arab, Arab Scottish or Arab British
Group C – Asian, Asian Scottish or Asian British 6Z Other ethnic group
3F Pakistani, Pakistani Scottish or Pakistani British
3G Indian, Indian Scottish or Indian British Group G – Refused / Not Provided By Patient
3H Bangladeshi, Bangladeshi Scottish or Bangladeshi British 98 Refused / Not provided by patient
3J Chinese, Chinese Scottish or Chinese British
3Z Other Asian, Asian Scottish, Asian British Group H – Not Known
99 Not known

Childsmile outcome at 6-8 weeks

P Provide
S Signposted to
D Discuss with
R Request assistance from
W Refused

Tools used to support developmental assessment

01 PEDS 07 SSLM
02 PEDS:DM 08 M-CHAT
03 ASQ 3 09 Eyberg CBI
04 SOGS II 10 Other
05 SDQ 11 None
06 ASQ:SE

Issue Status Code

When an issue is entered for the first time, the issue status code must be entered.
Subsequent pre-printed issues must have status updated in the issue status column
0 Referred /Assistance requested
1 Issue ongoing
(#) 2 No longer has issue
(#) 3 Amend issue (must add new issue)
4 No information available
(#) 5 Issue/Code incorrectly recorded
6 Discharged due to DNA
NB SYMBOL (#) INDICATES USE OF THIS CODE WILL CLOSE A PROBLEM

Health Plan Indicator (HPI)
C Core Programme
A Additional Programme
U Unknown
Support Needs Status Parental consent to share information from
0 Not active on SNS this review with early education and childcare
1 Active – not yet notified to Doctor Y Yes
2 Active – not yet assessed N No
3 Active – being assessed X Not sought
4 Previously on SNS
8 No Planned Assessment

27-30 MONTH REVIEW 160215