GIRFEC - Highland Pathfinder

Elaine Kirk

Super Moderator
Highlands collect information on every child . This thread covers the forms to be completed with details of each child . I will give each form it's own post.
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CHILD’S FORENAME:
SECOND FORENAME:
REGISTERED SURNAME :
Family Name (s)
Forename Known As:
SURNAME AT BIRTH
DOB
CHI
Sex at Birth
Telephone
1st Address:
Post Code
Mobile:
Telephone:
2nd Address
Post Code
Mobile Phone:
Nursery/School Attending
Email:
Family Members in Household/s
Surname
Forename
DOB
CHI
Place in Family to Child
Significant Medical History
Additional Residents in Household/s
Surname
Forename
Relationship to Family
Other Associated People (eg. Grandparents, Childminders)
Name
Relationship
Address/ Telephone
G.P
Health Visitor
School Nurse
Practice

Parental Responsibility
Child’s Current Religion
Not Disclosed
Date
Child’s Ethnic Group
Not Disclosed
Date
Child’s Ancestry Related Health Risk
Give details
Child’s First Language
Mother’s First Language
Father’s First Language
Child’s Communication Difficulties YES/NO
(includes vision and hearing impairment as well as language)
If YES, please state
Mother’s Communication Difficulties YES/NO
(includes vision and hearing impairment as well as language)
If YES please state
Father’s Communication Difficulties YES/NO
(includes vision and hearing impairment as ell as language)
If YES please state
Interpreter Needed: Child YES/NO Mother YES/NO Father YES/NO Carer YES/NO
Interpreter Arranged: Yes/ No
Name:
Telephone:
Communication Assistance Required
Child
Please identify
Mother
Please identify
Father
Please identify
Mother in Employment: Yes/No Maternity Leave:
Occupation:
Father in Employment: Yes/No
Occupation:
Part time/Full time
Days Worked
Part time/Full time
Days Worked
Family Pets in household
 

Elaine Kirk

Super Moderator
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Child’s name
DOB
CHI
(OR USE LABEL)
Vaccine/Age
2 months
3 months
4 months
12 months
13 months
3-5 years
13-18 years
Diptheria, tetanus, pertussus, polio, Hib
DTaP-IPV-Hib
DTaP-IPV-Hib
DTaP-IPV-Hib
DTaP-IPV- DTaP-IPV
dT-IPV
Meningocccal C (Men C)
Men C
Men C
Hib-MenC
Hib- Men C
MMR
MMR
MMR
PCV
PCV
PCV
PCV
Hepatitis B (to high risk category patients only)
Birth (within 2 days)
1 month
2 month
12 month (booster)
BCG (to high risk category patients only)
Neonates +
6 years+(if not given as neonate)
Mantoux
Mantoux
BCG
BCG
BCG
Other Vaccines
Date
Other Vaccines
Date
Note Allergies
REACTIONS TO ANY IMMUNISATIONS
Date
Action taken
 

Elaine Kirk

Super Moderator
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Child’s name
DOB
CHI
(OR USE LABEL)
Over and above Hall 4 schedule, recording heights and weights to be recorded if clinical need is indicated or in child protection issues are identified. Plot on the relevant Growth Chart.
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Elaine Kirk

Super Moderator
I realise some of these are expected but the only way to show how many bits of information are floating around and the potential for misinformation to remain uncorrected e.g. 2 out of the 4 forms already posted have child protection details - will all if these be amended if no cause for concern is found?
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Elaine Kirk

Super Moderator
Child’s name
DOB
CHI
(OR USE LABEL)
Date
Signature
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Safe:
e.g. Child protection, family of concern. Practical care i.e home safety. Physical, social, emotional dangers i.e bullying. Parental support concerns, & identifiable risk factors i.e parental drug and alcohol problems.
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Healthy:
e.g. Vision, hearing, growth, immunisations, medical conditions, i.e. asthma, epilepsy, attention deficit disorder, developmental co-ordination disorder, genetic disorders, allergies, skin conditions, enuresis, encopresis,
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Achieving:
e.g. Communication, language acquisition & expression, developmental milestones.
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Nurtured:
e.g. provides love emotional warmth attachment, play stimulation & encouragement, physical & emotional care and an educationally rich environment. Accessed parenting programmes, accesses healthcare appropriately.
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Active:
e.g. Known physical disabilities. Receives stimulation & encouragement to learn; child able to access play & leisure activities.
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Responsibility & Respected
e.g. Any prejudices and tensions, level of resilience, self esteem, sense of identity, experienced loss/bereavement.
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Included:
e.g support from family, community, child has friends. Appropriate attendance at playgroup/nursery.
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Associated Agencies Involved:
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snapshot of form
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the following all have boxes for data as shown above

Analysis
Date & Time
Signature
Child/Parental Views
Date & time
Signature
Child/Parental Actions
Date & Time
Signature
Professional Actions
Date & Time
Signature
Consent to Share Information if indicated
Signature
Date
Verbal Consent YES NO
Written Consent YES NO
Date
Complete
Health Plan Indicator:
If additional issues identified do you need to complete the My World Triangle Assessment and or care plan ?
Review Date:
YES
 

Elaine Kirk

Super Moderator
Page 1 of 4
Name
DOB
CHI
(OR USE LABEL)
Contact Codes : H = Home C = Clinic SC =School T = .Telephone EW = Elsewhere B=Base
Contact Log Record contacts and telephone calls from family members and practitioners
Date & Time
Contact Code
Signature
NHS Highland Version 4 Nov 08 PHNR F19
Lifestyle Factors

Identify strengths and pressures in the following: Physical, mental and emotional health, diet/exercise, leisure activities, relaxation, dental health use of tobacco and drugs.
Pressures
Strengths
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Family Environmental Factors
Identify strengths and pressures in the following: support from family and friends, employment, unemployment, parenting enough money, housing.
Pressures
Strengths
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Health Promotion discussed:
Breast / testicular self examination
Other topics:
Family Member Health Assessment/Contact Form
Page 3 of 4
Name
DOB
CHI
(OR USE LABEL)
Analyse the strengths and pressures identifying the impact on the person’s wellbeing
Date & Time
Signature
Family Member’s Views
Date & time
Signature
NHS Highland Version 4 Nov 08 PHNR F19
NHS Highland Version 4 Nov 08 PHNR F19
Family Member’s Actions
Date & Time
Signature
Professional Actions
Date & Time
Signature
Consent to Share Information if indicated
Signature
Date
Verbal Consent YES NO
Written Consent YES NO
Date
Complete
Health Care Plan for any needs identified
Review Date:
Mood Assessment and Edinburgh Depression Score (as appropriate):
 

Elaine Kirk

Super Moderator
.

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Child’s name
DOB
CHI
(OR USE LABEL)
Date
Health Professional Signature
Mother in Employment: Yes/No Maternity Leave:
Occupation:
Father in Employment: Yes/No
Occupation:
Part time/Full time
Days Worked
Part time/Full time
Days Worked
Resident Partner: Yes/No No current partner Yes/No Partner non – resident: Yes/No
NEW PARTNER/ADDITIONAL RESIDENT DETAILS including Looked After Children
Forename
Surname
DOB/CHI
Employment
Resident
Yes/No
Relationship to Child
Parental Responsibility
Persons moved out of the Family Home give names and reason:
Family Bereavements:
With dates
Family Pets

FAMILY INFORMATION UPDATES
Date
Health Professional Signature
Mother in Employment: Yes/No Maternity Leave:
Occupation:
Father in Employment: Yes/No
Occupation:
Part time/Full time
Days Worked
Part time/Full time
Days Worked
Resident Partner: Yes/No No current partner Yes/No Partner non – resident: Yes/ No
NEW PARTNER / ADDITIONAL RESIDENT DETAILS including Looked After Children
Forename
Surname
DOB/CHI
Employment
Resident
Yes/No
Relationship to Child
Parental Responsibility
Persons moved out of the Family Home give names and reason:
Family Bereavements:
With dates
Family Pets
 

Elaine Kirk

Super Moderator
Page 1 of 5
Child’s name
DOB
CHI
(OR USE LABEL)
Summarise the Child’s World strengths and pressures within each section
Date Signature
How I Grow and Develop
Date
Pressures
Signature
Strengths
Analyse the Child’s Developmental Progress

What I need from those who care for me
Date
Pressures
Signature
Strengths
Analyse the impact on the child, the parents/carers ability to meet their needs

My Wider World
Date
Pressures
Signature
Strengths
Analyse the above information on how it may impact on the child

What are the child’s views about the impact of the strengths and pressures identified in their world?

Date
Signature
What are the parent/carers views about the impact of the strengths and pressures identified in their child’s world?
Date
Signature


Analysis
Date & Time
Signature
Child/Parental Actions
Date & Time
Signature
Professional Actions
Date & Time
Signature
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Elaine Kirk

Super Moderator
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CARE EPISODE NUMBER
Child’s name
DOB
CHI
(OR USE LABEL)
Date
Level of Risk
Care Aim
Timescale for Episode/Evaluation
Consent to Share Information received
YES
NO
Needs/Risks Identified link to SHANARI
Intended Outcomes for Episode link with SHANARI
Care Aims
1 Investigation
(assessment)
2 Prevention
(Anticipatory
3 Stabilisation
(Maintenance)
4 Facilitation
(Enabling)
5 Resolution
Curative
6 Improvement
(Rehabilitation)
7 Adjustment (supportive)
8 Relief
(Palliatives)
Version 4 Nov 08
Safe Healthy Active Nurtured Achieving Respected and Responsible
Action by Family Member/Child
Date
Signature
Action by Health Professional
Date
Signature
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Elaine Kirk

Super Moderator
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HANDOVER FROM HEALTH VISITOR TO SCHOOL NURSE
SUMMARY OF IDENTIFIED SHANARI ISSUES

Child’s name
DOB
CHI
(OR USE LABEL)
Date of Handover
Health Visitor Signature
School Nurse Signature
Child’s Pre School Education Centre:
Child’s Proposed School:
Child’s Health Plan Indicator Level:
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Safe:
e.g. Child protection, family of concern. Practical care i.e home safety. Physical, social, emotional dangers i.e bullying. Parental support concerns, & identifiable risk factors i.e parental drug and alcohol problems.
.
Healthy:
e.g. Vision, hearing, growth, immunisations, medical conditions, i.e. asthma, epilepsy, attention deficit disorder, developmental co-ordination disorder, genetic disorders, allergies, skin conditions, enuresis, encopresis,
.
Achieving:
e.g. Communication, language acquisition & expression, developmental milestones.
.
Nurtured:
e.g. provides love emotional warmth attachment, play stimulation & encouragement, physical & emotional care and an educationally rich environment. Accessed parenting programmes, accesses healthcare appropriately.

Active:
e.g. Known physical disabilities. Receives stimulation & encouragement to learn; child able to access play & leisure activities.
.
Responsibility & Respected
e.g. Any prejudices and tensions, level of resilience, self esteem, sense of identity, experienced loss/bereavement.
.
Included:
e.g support from family, community, child has friends. Appropriate attendance at playgroup/nursery.

Associated Agencies Involved:
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Elaine Kirk

Super Moderator
These are the childs girfec files not the Hospital/midwife/GP
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Mothers Name
DOB
CHI
Childs Name
DOB
CHI
MATERNAL INFORMATION
To be held separately from child health record
Obstetric History Summary
Live Births
Drugs:
Misc before 12 weeks
TOP’s
Allergies:
Stillbirths
Neonatal deaths
Blood Group:
Caesarean Sections
Birthweight <2.5.kg
Parity + EDD
Gestation <37 weeks
Number expected to be born in this pregnancy
Singleton / Twin
Risk Factors:

Additional Information:
 

Elaine Kirk

Super Moderator
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Mother’s name
DOB
CHI
(OR USE LABEL)
To be completed in the antenatal period until the child is born. Thereafter significant events that impact on the child will be recorded in the child’s chronology.
Significant events for the Mother may include: non attendance at health appointment, failed appointments, attendance at A/E, or out of hours service, injuries, anonymous referral of concern, request for information due to concern, case conference/meeting, request to other services, change in family dynamics, moving house, housing problems, admissions to maternity units, issues/risks that can make a mother more vulnerable.
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