# _______
Risk Factors for Substance Exposed Newborns
By Interview (check all that apply)
1.
2.
____
____
3.
____
4.
____
Mother reports binge, moderate or heavy alcohol use* just before or during the pregnancy.
Mother reports drug use including misuse of prescription or over-the-counter medications just
before or during this pregnancy.
Mother reports that her partner or another person living in the home has a problem with alcohol or
drugs.
Mother reports history of intimate partner violence in the past year.
From review of mother’s medical record or by interview
5.
6.
7.
8.
____
____
____
____
9.
10.
11.
12.
____
____
____
____
Positive drug test during the pregnancy
History of drug/alcohol treatment in the past 24 months
Inadequate prenatal care (5 or fewer visits, first visit after 20 weeks)
Unexplained change in the continuity of prenatal care (i.e., late change in prenatal care provider
or birth hospital)
Previous diagnosis of HIV, hepatitis B or C
Previous child with FAS or alcohol-related birth defects
Previous DHS/Child Welfare involvement
History of incarceration or juvenile detention in either parent in the past 24 months
From review of the baby’s medical record
13.
____
Unexplained neonatal depression, seizures, jitteriness, or signs suggestive of Neonatal Abstinence
Syndrome
By observation of parents
14.
____
15.
____
16.
____
Either parent shows physical signs of substance use or withdrawal (i.e., apparent needle tracks;
abundant nasal discharge not associated with allergies or a cold; marked dental caries; skin lesions
or other signs of poor physical health and hygiene)
Either parent has inappropriate behavior (i.e., disorientation, somnolence, loose associations,
irritability or unfocused anger)
Either parent smells of alcohol or chemicals
Actions Taken (check all that apply)
_____ Referral for brief smoking educational intervention (respiratory therapy)
_____ Referral to the Medical Social Worker for alcohol education intervention
_____ Referral to the Medical Social Worker to initiate SEN algorithm and conduct further evaluation and development of safe care plan
for the baby (one or more risk factors positive).
_____ Orders obtained for urine drug testing on mother and baby (one or more risk factors positive)
Results





Urine drug test on baby ___ yes ____no
Urine drug test on mother ___ yes ___ no
Safe care plan developed ___yes ___no
DHS child welfare referral made ___yes ___no
Baby placed in foster care ___yes ___no



Mother referred to drug/alcohol treatment program
___yes ___no
Mother completed depression screen ___yes ___no
Mother referred to mental health services ___yes ___no
Medical complications of the mother ___ yes ___no
Medical complications of the baby ___yes ___no
Comments (include results of drug screens, description of medical complications of mother or baby):
*for women, binge = 4 or more drinks per occasion; moderate = 4-7 drinks per week; heavy = more than 7 drinks per week or binge
drinking on 5 or more days in the past 30 days.
Patient Identification
SH0234 (10/20/08)
Sacred Heart Medical Center
Risk Factors for Substance Exposed Newborns
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