CREATING A CHILD MEDICAL VISIT
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How to use this PDS section: Each time a participant reports any type of medical visit for a target child, staff must document the visit in this section of PDS. If there are multiple births for one pregnancy, e.g. twins, then medical visits must be created for each child.  

Why this information is important: Supporting access to health care resources, promoting consistent preventative health care, and encouraging healthy habits are an essential part of HFM service delivery.

HFM policies related to this PDS section: Health Care Access Policy

Step-by-Step Instructions  

Fields with an asterisk (*) are required.

1. Go to the Participant Profile page for the child’s parent. On the participant's profile page under the Family section, find the child for whom you want to create a medical visit and click Edit.

Alternatively, see the Creating a Home Visit Record  section of the PDS manual for instructions on navigating to the Child Medical Visit page using the Jump To feature in the home visit record.

2. You are now on the Family Summary page. Click the Child Medical Visits tab at the top of the screen.

3. Under the “Family Children” section you will see the child's name. Click Create New Medical Visit Record.

4. Enter information about the medical visit in the “Medical Visit Information” section.

4.1. Child's Name: The child's name will auto-populate here.  

4.2. * Date of Visit: Enter the date the child's medical visit occurred. Only medical visits that have happened should be documented in PDS. The date of medical visit must be equal to or before the date of data entry.

4.3. * Type of Visit: Select the type of visit that occurred from the dropdown menu. Two medical visits cannot be entered for the same day unless they have different visit types.  

• ER illness: Emergency room medical visit focused on an illness, such as the Flu. When selecting ER illness, the Nature of ER Illness is an additional field that is required (see below).
• ER injury: Emergency Room medical visit focused on an injury, such as a sprained ankle.  
• Hospital procedure/treatment: a scheduled visit to a hospital to have a procedure or treatment, such as dialysis, completed.
• Immunization only: a visit to a hospital, office or other health care setting where an immunization is received without additional medical services, such as an immunization at birth or a visit to urgent care for a flu shot.  
• Office dental: an office visit focused on the dental health of a child.
• Office follow-up: office medical visit that is a follow up to a previous medical visit. For example, if a child sees the pediatrician for an illness, the pediatrician may require that the child return to the office for a follow up visit.
• Office illness: office medical visit focused on an illness, such as the Flu, that does not occur in an Emergency Room or Urgent Care setting.
• Office injury: office medical visit focused on an injury, such as a sprained ankle, that does not occur in an Emergency Room or Urgent Care setting.  
• Office mental health: office visit focused on the mental health of a target child that does not occur in an Emergency Room or in an Urgent Care setting.
• Office well child visit: routine appointment focused on child health and development.
• Urgent Care illness: Urgent Care medical visit focused on an illness, such as the Flu, that does not occur in an Emergency Room or at a participant's physician's office.  
• Urgent Care injury: Urgent Care medical visit focused on an injury, such as a sprained ankle, that does not occur in an Emergency Room or at a participant's physician's office.  
• Other, specify: This option should only be chosen if none of the above options apply. Enter information about the type of medical visit in the Visit Details field (see below).
• Inactive visit types: ER referred by PCP illness, ER routine illness, ER emergency, Hospital injury, ER (for routine care), Office illness/sick, Urgent Care and In hospital are inactive types of medical visits that cannot be selected.

  

4.4 * Nature of ER Illness (required if ER Illness is selected as Type of Visit):

• Crisis: Use of an Emergency Room to diagnose or treat an acute illness such as a urinary tract infection.
• Non-Crisis: Use of an Emergency Room to diagnose or treat a routine illness in which the participant was not experiencing a health crisis such as chronic diaper rash.  
• Referred by PCP (for crisis or non-crisis visits): Use of an Emergency Room to diagnose or treat an illness based on the directions given from a primary care physician regardless of whether the target child was experiencing a health crisis or not.  

 

4.5. Visit Details: Enter any information you obtained about what took place during the medical visit such as the reason for visit (e.g. the child had a fever of 102 degrees).

4.6. Add Immunization: If the child received or was offered immunizations at this medical visit, see Creating an Immunization Record for documentation instructions.  

5. Spell Check: Select to check the spelling of text entered on this page.

6. Save and Close: Select to save the information and return to the Child Medical Visit page.

7. Save and continue: Select to save the information and return to the child medical visit record.  

8. Cancel: Select to return to the Child Medical Visit page.  

9. Print: Select to print the Medical Visit record. Information must be saved before using this feature.  

10. Ready for Supervisor Review: Check Record is ready for Supervisor Review? when the Child Medical Visit record is ready for review.

11. Supervisor Review Information: If a supervisor makes comments on the record, comments will appear in the “Supervisor Review Information” section.