Brush, Book, Bed QI Project Data Collection Brush, Book, Bed QI Program Data Entry Form Practice Name * Pediatric Associates of Springfield The Christ Hospital OSU Primary Care of Lewis Center Dayton Children's Hospital Foster Care Clinic Pediatric Associates of Mt. Carmel University Premier Pediatricians Other Practice Name Provider Name * Date of Visit: * Age of Patient at Time of Visit * Less than 6 months 6 months - 12 months 1 year 2 years 3 years 4 years 5 years 6 years 7 years or older Other Age of Patient at Time of Visit Please check all items with documentation in the chart for this visit: * Early literacy Relationships or bonding Oral health Fluoride varnish application Sleep Safe sleep Bedtime routines Brush, Book, Bed Complete visits will consist of discussion of at least 4 topics: Early Literacy; Oral Health; Sleep; Bedtime Routines. Items will be analyzed in data independently as well as grouped to determine results. Were materials offered and provided during this visit (if applicable)? * Book - offered and accepted Book - offered and declined Oral health supplies (toothbrush and/or toothpaste) - offered and accepted Oral health supplies (toothbrush and/or toothpaste) - offered and declined Handout/printed materials on related topic - offered and accepted Handout/printed materials on related topic - offered and declined No record of supplies/materials offered Other notes related to BBB or the program for this visit: Submit If you are human, leave this field blank.
