Perinatal Risk Assessment Discharge Tool
Patient Name: _______________________________________
MR#: ________________
Risks
Risk Categories
Interventions
Signature & Date
Initiate
Problem
Medications
 Adherence/complications
 Anticoagulants
 Anti-depressants/Psychotropic
medications
 Insulin
 Methadone/Long term narcotics use
 Oral hypoglycemic agents
 Polypharmacy
 Other problem medications
(1, 2, 3, 4, 5)
(1, 2, 3, 4, 5)
(1, 2, 3, 4, 5)
1.
2.
3.
(1, 2, 3, 4, 5)
(1, 2, 3, 4, 5)
(1, 2, 3, 4, 5)
(1, 2, 3, 4, 5)
(1, 2, 3, 4, 5, 6)
4.
5.
6.
Maternal
Medical
Risks
 Asthma/Pulmonary Disease
(Requiring Medication within the last
90 days and/or at discharge)
 BMI < 18.5 or > 40
 Chronic Hypertension:
pre-pregnancy
 DVT/Thromboembolism (TE)
 Physical Disability
 Sickle Cell Disease/
hemoglobinopathy
 Other Medical Conditions (specify)
______________________________
(1, 2, 3, 4, 5, 6, 7)
1.
2.
(1, 2, 4, 5, 6, 7)
(1, 2, 3, 4, 5, 6, 7)
3.
(1, 2, 3, 4, 5, 6)
(2, 4, 7)
(1, 2, 3, 4, 5, 6, 7)
4.
(1, 2, 3, 4, 5, 6, 7, 8)
5.
6.
7.
8.
Post-discharge phone call within:  24 - 72hrs
Discharge summary communicated to OB/GYN and/or PCP:
 Fax
 Mail/Email
Medication specific strategies (RN or pharmacist)
 Communicate monitoring plan to patient/caregiver
 Review (applicable) medication/monitoring plan
 Teach using “Teach Back” method
Review specific strategies for managing adverse drug events
Out-Patient follow-up/referrals (check all that apply)
 Cardiology
 Endocrine
 Home Health Visit
 Mental Health
 WIC Referral
 Medical Evaluation within 2 weeks
Other (specify)________________
Post-discharge phone call within:  24 - 72hrs
Discharge summary communicated to OB/GYN and/or PCP:
 Fax
 Mail/Email
Medication specific strategies
 Communicate monitoring plan to patient/caregiver
 Review (applicable) Medication/Monitoring plan
 Teach using “Teach Back” method
In-Patient Consults (check all that apply):
 Cardiology
 Dietary/Nutrition
 Endocrine
 Mental Health
 Respiratory
 Social work
Out-Patient follow-up/referrals (check all that apply)
 Cardiology
 Endocrine
 Home Health Visit
 Mental Health
 WIC Referral
 Medical Evaluation (within 2 weeks)
Teaching (risk-specific teaching)
DHMH Referral form completed
Other (specify)________________
Complete
Perinatal Risk Assessment Discharge Tool
Patient Name: _______________________________________
MR#: ________________
Risks
Risk Categories
Interventions
Signature & Date
Initiate
PregnancyRelated
Risks
 Age < 18
 Age > 40 & primigravida
 Diabetes
 Gestational Diabetes
 Insulin Dependent Diabetes
 Pregestational Diabetes
 Requiring Medication at
Discharge
 At risk for DVT/
Thromboembolism (TE)
 Hypertensive Disorders
 Chronic Hypertension
 Gestational Hypertension
 Pre-eclampsia/Eclampsia
 Late/Inadequate/No Prenatal
Care (< 5 visits)
 Positive Toxicology Screen
 Sexually Transmitted Infection/
Human Immunodeficiency
Virus/ Hepatitis
 Other Pregnancy or deliveryrelated risks
Specify_______________________
(1, 2, 3, 4, 5, 6, 7)
(1, 2, 3, 4, 5, 6, 7)
1.
2.
3.
(1, 2, 3, 4, 5, 6, 7)
(5, 6)
4.
(1, 2, 3, 4, 5, 6, 7)
5.
(2, 5,6 )
(1, 2,3, 4, 5, 6, 7)
(2, 3, 5, 6,7)
(1, 2, 3, 4, 5, 6, 7, 8)
6.
7.
Post-discharge phone call within:  24 - 72hrs
Discharge summary communicated to OB/GYN and/or PCP:
 Fax
 Mail/Email
Medication Specific Strategies (as applicable)
 Communicate monitoring plan to patient/caregiver
 Review medications/Monitoring plan
 Teach using “Teach Back” method
In-Patient Consults (check all that apply):
 Cardiology
 Dietary/Nutrition
 Endocrine
 Mental Health
 Respiratory
 Social work
Out-Patient follow-up/referrals (check all that apply):
 Cardiology
 Endocrine
 Home Health Visit
 Mental Health
 Medical Evaluation (within 2 weeks)
Teaching (risk- specific teaching)
DHMH Referral Form Completed
Other (specify)_________________________
Complete