Mo. Code Regs. Ann. tit. 19, § 40-6.010
PURPOSE: ‘This rule establishes the forms and protocol to be used by health careproviders toimplement theperinatal substance abuse legislation in sections , 191.725,191.741 and 191.743, RSMo. (1) All licensed health care providers who provide obstetrical and gynecological care to pregnant women shall use the Department of Health form MCFH-4, the protocol required by section 191.741, RSMo, in Appendix A of this rule or any other assessment form which documents the substance abuse risk status of each patient. The medical record shall show documentation of this assessment. (2) The health care providers designated in section (1) of this rule shall have all patients sign the Department of Health form MCFH-3 in Appendix B of this rule, or any form which is signed and dated by the patient and which states the substances discussed. (3) To document the offer of service coordination for each pregnant woman at high risk for substance abuse, the health care providers designated in section (1) of this rule shall use the Department of Health form MCFH-2 in Appendix C of this rule and retain it in the medical record, or have documentation of the offer for service coordination and the woman’s response in the medical record. The health care provider shall make the referral for service coordination to the Department of Health by telephone or in writing. Auth: sections 191.725, 191.741 and 191.743, RSMo (Cum. Supp. 1991).* Original rule filed Feb. 2,1994, effectiue July 30,1994. *Or&+vd authority 1991.
Judith K. Moriarty (E/30/94) CODE OF STATE REGULATIONS seere!tarY Of state 19 CSR 40-6-HEALTH
MISSOURI DEPARTMENT OF HEALTH DIVISION OF MATERNAL, CHILD AND FAMILY HEALTH RISK ASSESSMENT FOR SUBSTANCE USE
1. Have you ever smoked cigarettes?
6. In the month before finding out you were pregnant, how many drinks of alcohol did you typically have per week?
6. In the last week, how many drinks of alcohol have you had?
7. Have you ever felt you should cut down on your drinking?
6. Have people annoyed you by criticizing your drinking?
9. Have you felt badly or guilty about your drinking?
IO. Have you ever had a drink first thing in the morning to steady your nerves or get rid of a hangover?
1. Merljuana 1) Have you ever used
2) Used in the past 12 months 3) Used since you became pregnant
COC~llll37 1) Have you ever used
‘2) Used in the past 12 months 3) Used since you became pregnant
Amphetamlnea? 1) Have you ever used
2) Used in the past 12 months 3) Used since you became pregnant
Halluclnogens7 1) Have you ever used
2) Used in the past 12 months 3) Used since you became pregnant
Sadatlves? 1) Have you ever used
2) Used in the past 12 months 3) Used since you became pregnant
Narcotfca? 1) Have you ever used
2) Used in the past 12 months 3) Used slnw you became pregnant
! no drug use ever - END 2. Have you ever felt you should cut down on your drugs?
3. Have people annoyed you by criticizing
4. Have you felt badly or guilty about your using drugs?
5. Have you ever used drugs first thing steady your nerves or get rid of a hangover?
2. 0 NO CWDER NI\ME YES 1.0 If no. go to next drug 1.0 I.0
l.n
If no, go to “ext drug 1.0 1.0
1.0
If no. go to next drug 1.0 1.0
I.0
If no. go to next drug 1.0 1.0
1.0
If no, go to next drug 1.0 1.0
1.0
If no. go to next drug 1.0 1.0.
your using drugs?
in the morning
Judith K. Moriarty secretarl Of State
NO
2.0
2.0 2.0
2.0
2.0 2.0
2.0
2.0 2.0
2.0
2.0 2.0
2.0
2.0 2.0
2.0
2.0 2.0
to
O&X ..^_. INSTRUCTIONS
There is no standard method of inquiring find it most comfortable end dietary habits. and finally. the the substance designed to move quickly and who therefore,
Although, this to document the assessment
CRITERIA FOR REFERRAL
A definite referral
1) respond affirmatively
2) respond affirmatively
If referral is refused, she should be reassessed
Periodic reaseesement
1) have a history was known
2) Have signficant lack of academic co-dependency,
Regular monitoring may provide use. if the benefits of abstinence
ALTERNATIVE
For those drugs which is most prevalent
1) Marijuana _ grass. weed, 2) Cocaine -coke, 3) Amphetamines 4) Hallucinogens 5) Sedatives (tranq., diazepines. 6) Narcotics (codeine. 7) PCP angel dust, zombie. supercools, 6) Inhalants (amyl nitrite,
Judith K. Moriarty StrrCtary Of state FOR USE
and natural
In this way.
illicit substances. use/abuse of immediate but efficiently; require further evaluation.
form is not a required and it’s results, as well as the date.
should be offered
to two or more of questions
to recent use or continued
should be offered
of prior heavy use of alcohol
to them, OR
psycho-social success, lack of peer or social support depression.
TERMINOLOGY
listed under question in your area. For your convenience.
joint.
crack, base. blow. - meth. crank, uppers, speed, crystal, - LDS. acid. love drug, cectus, buttons, peyote, magic mushrooms.
demerol.
toluene) about alcohol
to introduce
it is easy to progress Alternatively. the subject family members by highlighting
component
to all women who:
at each subsequent
to those women who:
risk factors: such es a positive
history of prostitution
the pregnancy client with sufficient motiviation are stressed and any positive
FOR ILLICIT SUBSTANCES
number 11. it may be more appropriate
reefer, kit, herd, hashish, hash oil. toot, rock, snow, uptown.
barb.) blues, downers. percodan. heroin, methadone) green. -huffing tuleo, glue, kick, poppers, or drug abuse, during this line of questioning from over-the-counter can be introduced and progressing any “red
of the permanent medical location
7 through 10 or questions
use despite awareness
visit end again. offered
or other drugs, but deny current
family history
systems,
or multiple STD’s etc.
results are reinforced.
several alternatives
ice. dex, black beauties,
yellow jackets, -schoolboy, the initial work-up. Many health care providers after inquiring and prescribed medications during to the habits of
flags” which identify women
record,
and name of the provider.
12 through
of their pregnancy
use or use since
for substance
lack.of economic
to persevere
to utilize are suggested
beanies,
rainbows. ludes, smack. junk, downtown.
snappers, rush. about matters
the family history; the individual. at risk
it may be retained
15. OR
status.
referral based on her Statue,
their pregnancy
abuse, physical
independence, friends who use drugs,
in their attempts
the “street names” or slang below:
copilots, beans.
reds. 19 CSR 40-6 , m
of general health to tobacco. alcohol by inquiring about The assessment is for substance use
in the client’s chart
status
or sexual abuse.
to discontinue
terminology
19CSR40-&HEALTH Division 40-Division of Maternal, Child and Family Health
4ISSOURI DEPARTMENT OF HEALTH )IVISION OF MATERNAL, CHILD AND FAMILY HEALTH iCKNOWLEDGEMENT OF COUNSELING
My health care provider has discussed with me the effects of:
ALCOHOL (BEER, WINE, WINE COOLERS, LIQUOR)
TOBACCO (INCLUDING SECOND HAND SMOKE)
cl
PRESCRIPTION DRUGS (WITHOUT DOCTOR ADVICE)
cl
cl OVER THE COUNTER MEDICATION (WITHOUT DOCTOR OR PHARMACIST ADVICE)
OTHER DRUGS (STREET) SUCH AS: CRACK/COCAINE, MARIJUANA, BARBITURATES,
cl AMPHETAMINES, ETC.
on my own health and the health of my unborn child.
LITERATURE GIVEN:
DOH PAMPHLET TOBACCO OTHER DRUGS
cl cl cl
ALCOHOL COCAINE
cl 0
I understand this information, and have been given the opportunity to ask questions concerning substance abuse in pregnancy.
I have been given a toll-free number to call if I should need information or assistance with the problem of substance abuse during my pregnancy.
:LIENT SIGNATURE DATE
‘ROVIDER SIGNATURE DATE
>W188‘M%2j MCFKP,4.0: ,’ ., MISSOURI DEPARTMENT DIVISION OF MATERNAL, INFORMED CONSENT FOR SERVICE COORDINATION
I hereby give permission for the purpose of receiving additional and which will be coordinated health care provider of my baby. My doctor/nurse for me during my pregnancy.
I understand the Department my consent, nor can any such
I understand that I may refuse these services at any time.
I have read the above material, and have been given an opportunity I may have regarding
I have read the above material, and have been given an opportunity I may have regarding
I am not interested in a referral
MAY USE REVERSE SIDE TO DOCUMENT OFFER OF REFERRAL AND CLIENT RESPONSE MO 580.1632 (7.92)
Judith K. Moriarty SemImY 01 state OF HEALTH CHILD AND FAMILY HEALTH REFERRAL
to have my name provided to the Missouri Department services which may be helpful to me and my family by the Department of Health. I understand my physician/
believes these services are important for my health and practitioner/clinic will continue to provide medical
of Health will not share any information about me without information be used for criminal prosecution.
to ask any questions
the service coordination referral process.
to ask any questions
the service coordination referral process.
to the Department of Health at this time.
(OVER,
19 CSR 40-6
of Health
the health care
MCFH-* 11.92)
19 CSR 40-6-HEALTH
offer for referral is refused by client, additional recommendations during subsequent visits may be documented below. I