GUIDELINES FOR COMPLETING THE BIRTH SCORE - DEVELOPMENTAL RISK SCREEN AND HEARING SCREEN FORM

I.  PURPOSE:

This section provides guidance to hospital personnel who are responsible for completing the Birth Score-Developmental Risk Screen and Hearing Screen form. This form is used to identify three special population groups. The Birth Score identifies newborns who are at greater risk for illness or death within the first year of life. The Developmental Risk Screen identifies newborns who are at greater risk for developmental delay. The Hearing Screen identifies newborns who are at potential risk for permanent hearing impairment. Infants at risk for any of these conditions are linked with appropriate health care providers to aid in helping them to achieve a maximum level of health.

II. GENERAL GUIDELINES:

1. Begin the screening process in the Labor room or Delivery room.

2. Print clearly. Complete as much of the form as possible.

3. Enter the hospital/birth center three or four digit code in the space at the top of the form marked “Delivery Hospital”.

4. Send the screening form with the baby to the Newborn or Neonatal Nursery.

5. Imprint the baby's addressograph in the upper right hand corner of the form.

6.  Complete the developmental risk screen questions and select only developmental codes from the list on the back of the form

7. Assure that only weighted values (in parentheses) are entered in boxes as score value.

8. Double check addition when calculating the Birth Score.

9. Enter the results of the newborn hearing screen.

10. Explain the three screening procedures and outcomes to the infant’s parent(s) before obtaining the parent’s signature on the form.

11. Complete the “Questions for Mother” section of the form.

12. Mail the Original Copy of the form to the Birth Score Office as soon as the form is completed. Place one copy in the baby’s medical chart and give one copy to the parent(s).