CPSP Final Chart Review Tool



Chart ID number: _____________________Chart ID number: _____________________Comprehensive Perinatal Services Program (CPSP) Chart Review ToolCPSP Provider:______________________________________________________Date:__________________ Clinic Staff Present: (List all staff present and title) _________________________________________________Perinatal Services Coordinator:_________________________________________________________________ITEMSFindings/NotesWeek started prenatal careNumber of OB visits/follows ACOG recommended scheduleClient Orientation is documented. (51348.d.1)Using approved assessment forms, initial, trimester and PP assessments completed. Nutrition AssessmentDiet evaluation used: 24 hr. recall ? food frequency questionnaire?Weight every visit; ?plotted on correct grid?Initial (within 4 weeks of initial visit)?Second Trimester?Third Trimester?PostpartumPsychosocial Assessment ?Initial (within 4 weeks of initial visit)?Second Trimester?Third Trimester?PostpartumHealth Education Assessment?Initial (within 4 weeks of initial visit)?Second Trimester?Third Trimester?PostpartumAll documentation includes time in minutesAll entries signed with name and CPSP titleAppropriate use of STT or other materialsAn individual care plan is in place that: Identifies client strengthsAddresses identified OB, health ed, psychosocial, nutrition needs. Care plan updated each trimester and postpartumList datesFollow up on risks/issues identified in care planAppropriate referrals documented including but not limited to: WICGenetic ServicesCHDP/Well Child Pediatric CareFamily Planning Dental Appropriate follow up of other referrals Who does case coordination? Dispensed or prescribed vitamin & mineral supplementPhysician supervision documented per protocolDelivery record in chart (use to obtain birth outcome data, follow up if LBW, preterm, elective delivery before 39 wks, c-section)Gender M FBirth weight ____lb. ______oz.Gestational age _______weeks Delivery method vaginal cesareanFeeding method: BreastFormula CombinationCorrective Action Plan: IssueAction RequiredPerson ResponsibleTarget Date ................
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