Information
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Document No.
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Audit Title
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Client / Site
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Conducted on
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Prepared by
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Location
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Personnel
Well Child Visits
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3-5 day visit
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1 Month Visit<br>
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2 Month Visit<br>
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4 Month Visit
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6 Month Visit
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9 Month Visit
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12 Month Visit
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15 Month Visit
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18 Month Visit
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24 Month Visit
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30 Month Visit
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36 Month Visit
Child Health and Enrollment Information Form
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Is the form complete? (No Blanks)
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Is the form signed by the parent in both boxes?
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Does the form indicate the child has any health or medical conditions?
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Has the form been updated annually?
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Has the administrator or a designee signed the form?
Child Medical/Physical Care Plan
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Is the form complete? (No blanks)
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Is the form signed and dated by a trainer (parent/guardian, certified professional)
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Have all childcare staff members who work with the child been trained and signed the form?
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Has the parent signed and dated the form?
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Has the administrator signed and dated the form?
Medication Form
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Has box 1 been completed, signed and dated by the parent/guardian? (No blanks)
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If box 2 is applicable, has it been completed, dated, and signed by a licensed physician/dentist/advance practice nurse?
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If box 3 is applicable, has it been completed correctly each time the medication has been administered?
Newborn Assessment (Only applicable if child is less than 6 months old on date of entry)
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Is the assessment in the folder?
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Does the assessment include the newborn hearing screening?
Peach Nutrition Assessment (Due within 45 days from date of entry and at 6 month intervals after initial screening)
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Was the screening completed within 45 days from the date of entry?
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Has the screening been updated every 6 months?
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Are all questions on the screening complete (no blanks)
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If the score was 4 points or above, there is documentation that the child has been referred to a registered dietician.
Immunization Records
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Are immunizations up to date for age?
Parent Agreement for Screenings (Updated Annually)
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Initial Parent Agreement was completed before screenings
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Parent Agreement has been updated annually
Vision Screening Questionnaire
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Newborn
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3-5 days
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1 Month
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2 Month
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4 Month
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6 Month
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9 Month
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12 Month
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15 Month
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18 Month
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24 Months
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30 Months
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Vision Screening with Acuity-36 Months
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If one or more risk factors have been identified, a copy of the vision screening questionnaire is shared with the family to discuss with the pediatrician.
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If one or more behavioral signs have been identified, a copy of the Vision Screening Questionnaire was shared with the family to discuss with the pediatrician and there is documentation of a referral to a pediatric eye doctor.
Hearing Screening Questionairre
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Newborn
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3-5 days
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1 Month
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2 Months
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4 Months
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6 Months
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9 Months
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12 Months
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15 Months
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18 Months
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24 Months
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30 Months
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Hearing Screening with Results for Each Ear (36 Months)
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If any screening shows risk factors or milestone indicators, an OAE screening has been conducted and results are documented in the folder.
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If the OAE screening was completed and the child failed in either or both ears, documentation of a referral and follow-up is in the child's folder.
Speech Screening (PLS-5) (Due within 45 days from date of entry and at 6 month intervals after initial screening)
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Screening was completed within 45 days of date of entry
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If the screening showed a concern, there is documentation of a referral and follow-up in the child's folder.
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Has the screening been updated every 6 months?
Sickle Cell Results
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Results are in the file if applicable
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If applicable, a referral has been made if the child tested positive and follow-up is documented in the child's folder.
Hemoglobin Results
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If the child is 7 months or older, a hemoglobin result is on file.
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If the hemoglobin result is lower than 11.2, a referral and documentation of follow-up in in the child's folder.
Lead Results
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Proof of a lead screening at 12 months of age is in the child's file.
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Proof of a lead screening at 24 months of age is in the child's file.
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If a lead result is 10 or above (considered abnormal), there is a referral and follow-up documented in the child's file.
Dental Screening
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A dental screening has been completed before the child transitions to preschool.
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If a child's dental screening requires follow-up, there is documentation of dental follow-up in the child's file.
Child Health Record
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There is a completed Child Health Record (no blanks) in the child's file.
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The Child Health Record has been updated in January, May and September (3 times per year)
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If there is a concern on the Child Health Record, referral and follow-up is documented in the child's file.
Growth Chart
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Growth charts are updated in the child's file 3 times a year- January, May and September
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If the growth chart (BMI) indicates that a child is underweight, overweight, or obese, there is documentation of referral and follow-up, as well as parent education in the child's file.
Child Observation Reports
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If applicable, Child Observation Forms are complete (no blanks) and filled out correctly.
Child Incident Reports
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If applicable, Child Incident Reports are complete (no blanks) and filled out correctly.
