Contact Log
Michigan Department of Health and Human Services
Maternal Infant Health Program
MIHP Agency Name	Beneficiary Name
Beneficiary Lost to Service at Visit Number Items not completed during the course of care (check all that apply)
RI only – no program requirements completed Prenatal and postpartum visit for maternal beneficiary Beneficiary visited by both RN and SW All POC 2 domains addressed Required referral for Stress/Depression	Action Plan discussed/completed Safety Plan Intervention (if required) MCIR immunization record in chart Required referral for Food/Nutrition
Date	Notes	Initials

Date	Notes	Initials
The Michigan Department of Health and Human Services will not exclude from participation in, deny benefits of, or discriminate against any individual or group because of race, sex, religion, age, national origin, color, height, weight, marital status, partisan considerations, or a disability or genetic information that is unrelated to the person’s eligibility.
MIHP CONTACT LOG INSTRUCTIONS
These instructions are intended to clarify data fields. If you have additional questions, please contact the MDHHS MIHP Team. A contact log is required in every MIHP chart. Providers may use the MIHP Contact Log or a provider specific form which provides spaces for the date, notes, and the initials of the professional or administrative staff person making an entry.
Beneficiary Lost to Service If a beneficiary was lost to service prior to completing all appropriate program requirements, put an “X” next to the program requirement(s) not completed from the checklist provided. If the beneficiary only received the Risk Identifier and no professional visits, check “RI only – no program requirements completed.”
Entries Required on Contact Log The Contact Log is required to document: 1. Attempts to contact the beneficiary (e.g., phone, text, email, letter, note on door, etc.) if there’s a gap in service between professional visits and from the last MIHP billable service to discharge. Logging routine contacts are not required, such as calling the beneficiary to confirm an upcoming appointment or to ask for directions to the beneficiary’s home. 2. Reason why the beneficiary has not been seen whenever there is a one-month gap in service. 3. Reason why the RN or SW did not visit the beneficiary during the course of care. 4. Reason why all appropriate POC 2 domains were not addressed during the course of care. 5. Reason why a required referral was not provided during the course of care. 6. Reason why the Action Plan was not completed during the course of care. 7. Reason why the required Safety Plan intervention(s) were not implemented during the course of care.
Using the Contact Log for Other Purposes (Not Required) The contact log may be used for other purposes as well. For example, you may use it to document: 1. Contacts with other service providers on behalf of the beneficiary. 2. Contacts among team members. 3. Decisions made among team members. 4. Any other information that would be useful for team members to have.