Free Nursing Case Closure Report, DPH 4771B - Wisconsin

File Size: 25.5 kB
Pages: 1
Date: February 13, 2007
File Format: PDF
State: Wisconsin
Category: Health Care
Author: dhfs/dph/beoh/lead and asbestos
Word Count: 463 Words, 2,872 Characters
Page Size: Letter (8 1/2" x 11")

Download Nursing Case Closure Report, DPH 4771B ( 25.5 kB)

Preview Nursing Case Closure Report, DPH 4771B
DEPARTMENT OF HEALTH AND FAMILY SERVICES Division of Public Health DPH 4771B (Rev 11/06)

STATE OF WISCONSIN ss. 254.15, Wis. Stats Phone (608) 266-5817 FAX (608) 267-0402

Case Management Of Children with Elevated Blood Lead Levels* *Elevated Blood Lead Level (EBLL) = 1 venous Blood Lead Level (BLL) >20 mcg/dL OR 2 venous BLLs of >15 mcg/dL drawn at least 90 days apart. Completion of this form is mandatory for agencies contracting with the Division of Public Health for program funding. Data will be used in the aggregate to assist research and project future service needs. Nursing case management should follow the Case Management Protocol in the Wisconsin Childhood Lead Poisoning Prevention Program Handbook. The case manager should discuss provisions for appropriate longterm developmental follow-up with the primary health care provider and caregiver. Managing Elevated Blood Lead Levels Among Young Children, Centers for Disease Control & Prevention, 2002. CHILD INFORMATION Name of Child - Last Current Street Address Indicate how it was determined that the child is in a lead safe environment: CASE CLOSURE Date Case Closed (mm/dd/yy) Name of Case Manager Telephone No. (include area code) Apt. No. City First MI Date of Birth (mm/dd/yy) Zip Code


Lead hazard remediation work complete, property met final visual clearance investigation, and dust wipe samples met clearance standards Child moved to a new property identified as lead safe The source of lead poisoning was not lead-based paint and the child is no longer exposed

Reason for Closure:

Minimum Closure Criteria Met: 2 BLLs <15mcg/dL at least 6 months apart and the child is in a leadsafe environment Moved, referral forwarded (if known, indicate new address below in comments) Unable to locate Family refuses further intervention

FOLLOW-UP OF DEVELOPMENTAL SCREENING TEST When the screening test indicates 2 or more delays, the standards of practice call for the test to be repeated in 2-4 weeks or a referral to a provider for a comprehensive developmental assessment. The results of these follow-up actions are: No follow-up needed; screening test within normal limits The results of a second screening test were normal The results of a second screening test or referral indicated delays in: Language Gross Motor Skills Fine Motor Skills Personal - Social Other (specify): Other (describe):

REFERRALS OR OTHER SERVICES The child or family is enrolled in: Head Start Birth to 3/Early Intervention Early Childhood Parenting

4-Year Kindergarten Refused referral

Children with Special Health Care Needs (Regional CSHCN Center) Other (describe):


S e n d c o m p l e t e d f o r m t o : DEPARTMENT OF HEALTH AND FAMILY SERVICES Division of Public Health Childhood Lead Poisoning Prevention Program P. O. Box 2659, Room 145 Madison, WI 53701-2659