Date PHN Problem Outcomes Actions Additional Information (specific for family) Initials Covered Need for Child will have a PHN will communicate all medical physical exam and necessary information to the follow-up. be screened for primary care provider. anemia. PHN will encourage the family and provider to make sure the child has a complete physical exam. PHN will encourage the family, Results of test for anemia: provider, or WIC clinic to test the Date for future blood testing: child for anemia. PHN will encourage the family to All children in the test all children in the home, Names and ages of other children in the home that home will be especially those under the age of should be tested: Need for tested for an EBLL. six. medical An EBLL will be follow-up. PHN will encourage family and recorded in the (continued) medical provider to include an child’s permanent EBLL in the problem list of the medical problem medical record. list. Potential for Child will be PHN will assess child’s current Specific dietary recommendations on dietary poor provided a diet diet, especially iron, vitamin C, assessment (check all that were recommended): nutrition. following the calcium, and total fat intake. Incorporate more iron rich by providing iron- MyPlate fortified cereals to young children or one serving of recommendations. lean red meat per day to older children. Provide adequate intake of Vitamin C by providing 2 servings of citrus fruit juices or fruits per day. Increase calcium intake to ensure 2 servings of dairy products or other calcium-rich foods a day. Other (Specify):
Problem Outcomes Actions Additional Information (specific for family) Date Covered PHN Initials Need for medical follow-up. Child will have a physical exam and be screened for anemia. PHN will communicate all necessary information to the primary care provider. PHN will encourage the family and provider to make sure the child has a complete physical exam. PHN will encourage the family, provider, or WIC clinic to test the child for anemia. Results of test for anemia: Date for future blood testing: Need for medical follow-up. (continued) All children in the home will be tested for an EBLL. PHN will encourage the family to test all children in the home, especially those under the age of six. Names and ages of other children in the home that should be tested: An EBLL will be recorded in the child’s permanent medical problem list. PHN will encourage family and medical provider to include an EBLL in the problem list of the medical record. Potential for poor nutrition. Child will be provided a diet following the MyPlate recommendations. PHN will assess child’s current diet, especially iron, vitamin C, calcium, and total fat intake. Specific dietary recommendations on dietary assessment (check all that were recommended): Incorporate more iron rich by providing iron- fortified cereals to young children or one serving of lean red meat per day to older children. Provide adequate intake of Vitamin C by providing 2 servings of citrus fruit juices or fruits per day. Increase calcium intake to ensure 2 servings of dairy products or other calcium-rich foods a day. Other (Specify):