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N -C. Deparrmenc of Environment, Health, and Natural Resources Page 2 4 <br />Division of General Services 1991 <br />CONTRACT ADDENDUM FY <br />Maternal Health 91- 5422 -068 <br />Office, Section, or Branch Contract `umber <br />Orange County Health Dept. Maternal Health <br />Contractor <br />ACLIVILV <br />8. Persons enrolled in the Health Deparbwe Maternity Program will be provided the <br />following services as daaa rated in their medical records: <br />(a) An estimated 100 % will receive an initial maternal health history which <br />consists of at least 7 of the following 9 components: medical; family; <br />surgical; imnmization (TD, Rubella) ; drugs /medication; mil; <br />eontraoeptive; obstetrical; and psydxwocial . <br />(b) An estimated 100 % will receive an initial physical examination which <br />consists of at least 6 of the following 8 eampoanents: thyroid; lungs; <br />breast; heart; abdomen; amities; pelvic (uterine size or fundal height) <br />and blood pressure. <br />(c) An estimated 100 % will receive routine laboratory services which consist <br />of at least 13 of the following cmponents: <br />(1) Blood Group,--initial visit <br />(2) RH Determination- initial <br />visit <br />(3) Antibody screen - (initial <br />visit and repeat as <br />indicated) <br />(4) Antibody Titer -(if <br />positive antibody screen <br />and repeat as indicated) <br />(5) Rubella Tnmaie Status <br />(6) C"= rrhea culture-initial <br />visit <br />(7) Gmxwrhea culture - repeat <br />L2\4 <br />(8) Pap Smear - initial visit* <br />(9) Wet No nnt- initial visit <br />(10) Urine Dipstick - (glucose <br />and protein each routine visit) <br />(11) Ketones - if indicated <br />(12) Screening for asymptomatic <br />ba�tAruria <br />(13) Quantitative Urine cultum -if <br />indicated <br />(14) Blood Glucose -(50g. glucose load/ <br />OGTr if indicated) <br />(15) Hgb/Hct-each trimester <br />(16) Hgb Electrophoresis -(if indicated and <br />with informed consent) <br />(17) chlamydia screen- initial visit <br />(18) Ch amydi.a repeat- L:L if previously <br />positive <br />(19) AF? Screening <br />(d) STS an the initial visit and a repeat STS in the M. <br />(e) Screening for Hepatitis B an the initial visit. <br />(f) An estimated 100 % will receive at least 4 of the following 6 components <br />an all si.fte*tent routine scheduled visits that take place often 14 weeks <br />gestation: Interim, hi9t0ry /r0&inS screening questions; weight; blood <br />pyre: fundal heicjht; fetal heart tares, and presentation. <br />*Unless last Pap Smear bane within last six months <br />Reviewed by <br />DEHNR 3300 (Revised 2/90) - <br />General Services Division (Review 1/95) Initials Dice <br />