Bureau of Community Health Nursing



Bureau of Community Health Nursing

School Based Health Center Clinical Review Tool FY 13

|Center: GRANTEE: Date: |

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|MCH Nurse Consultant: Annual ( |

|Certification ( |

|Data Summary FY 13 |

|Number of Active Charts | | | |Total =       |

|Randomly Selected for Review | | | | |

|OUTCOME INDICATOR | |# Records Reviewed |# Expected |# Completed |% in Compliance | |Performance Standard or State |

| | | | | | | |Average |

|24 Hour Access to Care |

|SCHOOL BASED HEALTH CENTER EVALUATION PROTOCOL |

| |CODE Part |EVALUATION |MET |NOT |N/A | CO: Commendation |

|EVALUATION ITEM |2200/ |MECHANISM | |MET | |COMMENTS KEY: R: Recommendations |

| |Contract | | | | |RQ: Required (typed bold) |

|School Based Health Centers must follow the criteria specified in the School-Based Linked Health Center Standards (Title 77: Chapter IV: Sub Chapter J) |

|I. Provider Responsibilities |

|The provider will provide services directly or by referral to |Contract V.A. |Student Medical Record | | | | |

|students (and their children if applicable) enrolled in school |Code: |Interview Staff | | | | |

|who have obtained written parental consent or are legally able to|2200.20 |P&P | | | | |

|give their own consent. |2200.60 |Marketing literature | | | | |

| | | | | | | |

|Services include but are not limited to: | | | | | | |

|1. Routine medical care | | | | | | |

|Physical exam (school or sports) | | | | | | |

|Lab screenings and other lab services | | | | | | |

|Immunizations | | | | | | |

|Gynecological examinations | | | | | | |

|STI testing and treatment | | | | | | |

|Pregnancy testing | | | | | | |

|Prenatal care | | | | | | |

|Nutritional education | | | | | | |

|Health education (including sex education & promotion of | | | | | | |

|abstinence) | | | | | | |

|Alcohol, tobacco, drug & substance abuse counseling | | | | | | |

|Mental health counseling | | | | | | |

|Other general counseling | | | | | | |

|Other support services | | | | | | |

| | | | | | | |

| | | | | | | |

|1. Presence of valid certification and license for all | |P&P | | | | |

|appropriate staff. Current collaborative agreement exists |2200.70 A.1, A.2 and|Personnel record | | | | |

|between Physician and the Advanced Practice Nurse. Current |2B |Posting | | | | |

|written guidelines exist between supervising Physician and |Contract | | | | | |

|Physician Assistant | |Note: On-site evidence| | | | |

| | |required | | | | |

|Personnel Continuing Education |2200.70. |Personnel Record or | | | | |

| | |Continuing Education | | | | |

| | |Log | | | | |

| 3. Midlevel practitioner (MLP) evaluation |Contract |Medical director | | | | |

| | |monitors clinical | | | | |

| | |practice of MLP. | | | | |

| | |Annual performance | | | | |

| | |evaluation with | | | | |

| | |clinical skills | | | | |

| | |assessment. | | | | |

|Standing orders, if utilized, are annually reviewed and signed by|2200.80.B.7 |P&P | | | | |

|the medical director or assigned physician to guide RN &/or MOA | |Standing Orders | | | | |

|in clinic. | | | | | | |

| | | | | | | |

|The provider refers students requiring more intensive services to|Contract 5.A |Student Medical Record | | | | |

|appropriate private/public agencies and maintains appropriate |Code: |Interview Staff | | | | |

|case management follow-up. |2200.110.c |P&P | | | | |

| | |Referral Tracking Log | | | | |

| | |Abnormal Lab Log | | | | |

| | | | | | | |

|II. Client Intake |

|All students must have the following information documented in |Code: |Student Medical Record | | | | |

|their medical chart: |2200.20 |Interview Staff | | | | |

|Name |2200.90 |P&P | | | | |

|Identification number |Contract V. | | | | | |

|Address | | | | | | |

|Telephone # | | | | | | |

|Sex | | | | | | |

|Age | | | | | | |

|Race | | | | | | |

|Ethnicity | | | | | | |

|Date services initiated | | | | | | |

|Eligibility Determination | | | | | | |

|Consent for treatment |Code: | | | | | |

|Consent for Release of information (if applicable) |2200.90.7 | | | | | |

|HIPAA Acknowledgement |2200.100.5A | | | | | |

|III. Medical Record |

|A. Each client will have a confidential individual medical |Code: |Student Medical Record | | | | |

|record that is current, detailed, and organized. |2200.20-60 |Interview Staff | | | | |

|Name & ID #s on every page |2200.100 |P&P | | | | |

|Entries dated/signed |Contract V. | | | | | |

|Entries legible |2200.100.5.b | | | | | |

|Problem list current |2200.100.5 | | | | | |

|Medication sheet | | | | | | |

|Allergy history |2200.100 | | | | | |

|Medical history | | | | | | |

|Immunization history | | | | | | |

|Vital signs documentation | | | | | | |

|Height/weight | | | | | | |

|BMI | | | | | | |

|Chief complaint for each visit | | | | | | |

|Physical exam for each visit | | | | | | |

|Treatment plan for each visit | | | | | | |

|Appropriate referrals and follow-up | | | | | | |

|Age appropriate anticipatory guidance | | | | | | |

|Dental Examination | | | | | | |

|Vision & Hearing Screening | | | | | | |

|HIV Screening and Counseling | | | | | | |

|STI Screening, Counseling and treatment | | | | | | |

|Lab tests (Hct/Hgb, PPD, UA, Lead, Blood | | | | | | |

|Glucose, others) | | | | | | |

|Global risk or developmental assessment: | | | | | | |

|by 3rd clinic visit and updated per AAP | | | | | | |

|Periodicity Table. | | | | | | |

|B. Risk Assessment components | | | | | | |

|Nutritional history | | | | | | |

|Family history | | | | | | |

|Social history | | | | | | |

|Alcohol | | | | | | |

|Drugs/tobacco | | | | | | |

|History of abuse | | | | | | |

|Sexual activity | | | | | | |

|Peer relationships | | | | | | |

|Academic history | | | | | | |

|Learning disability |Code: | | | | | |

|Behavioral problem |2200.20 | | | | | |

|The medical records contain sufficient information to justify the|Code: |Student Medical Record | | | | |

|diagnosis and treatment; accurate documentation on assessments |2200.100 |Interview Staff | | | | |

|and services is present. |A-X |P&P | | | | |

|Medical records are secured to protect them from unauthorized |Code: |Interview Staff | | | | |

|use. |2200.100.7.e |P&P | | | | |

| | |Observation | | | | |

|IV. Scope of Services |

|A. The center provides appropriate clinical services based on |Code: |Student Medical Record | | | | |

|student’s complaint/needs assessment which may include: |2200.60.a.1 | | | | | |

|Basic Medical Services | |Interview Staff | | | | |

|Reproductive Health Services | | | | | | |

|Sexuality Assessment |2200.60.a.2 |P&Ps | | | | |

|Abstinence counseling | | | | | | |

|Gynecological exam | | | | | | |

|Diagnosis and treatment of STIs: Required on-site in | | | | | | |

|clinic | | | | | | |

|Family planning | | | | | | |

|Prescribing, dispensing, referring for | | | | | | |

|contraception. Informed of method | | | | | | |

|specific risks and side effects. Method | | | | | | |

|specific consent signed. | | | | | | |

|Pregnancy testing | | | | | | |

|Treatment/referral for prenatal and postpartum care | | | | | | |

|Cancer screening and education |2200.60.b | | | | | |

|Mental Health Services | | | | | | |

|Mental health assessment | | | | | | |

|Individual, group and family counseling | | | | | | |

|Crisis intervention | | | | | | |

|Consultation: school administrators, parents, teachers & students| | | | | | |

|Substance abuse services to include assessment, education, | | | | | | |

|referral and supportive counseling | | | | | | |

| | | | | | | |

| | | | | | | |

|Emergencies | | | | | | |

|Parents are notified. | | | | | | |

|The medical record case notes reflect emergency plan. | | | | | | |

|School Administration notified | | | | | | |

|Emergency Kit checked monthly | | | | | | |

|Child Abuse - Suspected child maltreatment |2200.60.f | | | | | |

|is reported immediately when reasonable |2200.60.e | | | | | |

|cause to believe a child known to the | |Mandated Reporting Act | | | | |

|Center is being abused/neglected. |2200.60.g |P&P | | | | |

| | | | | | | |

|V. Clinical Operations |

|A. Pharmaceuticals |Code: |Interview Staff | | | | |

|Pharmaceuticals are stored in a separate, |2200.80.b.6 |P&P | | | | |

|locked cabinet or refrigerator (as indicated) |225ILCS85 |Observation | | | | |

|and dispensed appropriately. (Refrigerator | | | | | | |

|log maintained. | | | | | | |

|There is an adequate system for monitoring inventory and |2200.60a11 |Tracking Log | | | | |

|expiration of pharmaceuticals. |225ILCS85 |Interview Staff | | | | |

| | |P&P | | | | |

|Diagnostic tests are ordered, tracked and results reported in a |Code: |Tracking Log | | | | |

|timely manner. |2200.50.c |Interview Staff | | | | |

| | |P&P | | | | |

|VI. Continuous Quality Improvement |

|Patient satisfaction survey |2200.130 |QA Plan | | | | |

|Frequency (at least annually) | |Interview Staff | | | | |

|Results | |P&P | | | | |

|Action taken | | | | | | |

|Internal clinical review |2200.130 |QA Plan | | | | |

|Frequency (at least annually): by Medical Director, APN/PA or RN | |Interview Staff | | | | |

|Coordinator | |P&P | | | | |

|Results | | | | | | |

|Action taken | | | | | | |

|Overweight and Obesity Project |2200.130 |QA Plan | | | | |

|How is student identified | |Chart Review | | | | |

|Intervention | |Interview Staff | | | | |

|Follow-up | |P&P | | | | |

|Evaluation Plan | | | | | | |

|Mental Health |2200.130 |QA Plan | | | | |

|MHPET completed | |Interview Staff | | | | |

|Findings | |P&P | | | | |

|Action taken | | | | | | |

|E. STI Screening, Diagnosis, and Treatment | | | | | | |

|IDPH Screening Reports Results/Trends | | | | | | |

|Increase in Testing/Screening: yes or no; if no, why not; | | | | | | |

|barriers | | | | | | |

|Action taken by MCH Nurse to resolve | | | | | | |

|Action taken by SBHC to resolve | | | | | | |

|VII. Administration | | | | | | |

|CLIA Certification up-to-date. Valid certification and license |Code: |Interview Staff | | | | |

|is available and current for all appropriate staff |2200.80b2c |P&P | | | | |

| |2200.70 |CLIA License | | | | |

|The Advisory Board has met annually and minutes are available. |Code: |Interview Staff | | | | |

| |2200.30.a |P&P | | | | |

| | |Advisory Board Minutes | | | | |

|The organizational chart has been reviewed by clinic staff and is|Code: |Interview Staff | | | | |

|current. |2200.30.c |P&P | | | | |

| | |Org. Chart | | | | |

|Policy and Procedures are reviewed annually by clinic staff and |Code: |Interview Staff | | | | |

|updated as needed. Documentation noting review of policies is |2200.40b |P&P | | | | |

|evident (i.e., current date and signatures of all clinic staff). | | | | | | |

| | | | | | | |

| | | | | | | |

|Waiting areas, private exam rooms, lab room, restrooms are |Code: |Interview Staff | | | | |

|adequate and well maintained, and OSHA written exposure plan |2200.80b |P&P | | | | |

|followed. | |Observation | | | | |

| | |OSHA Plan | | | | |

|Marketing and Community Outreach is demonstrated. Methods might |2200.140 |P&P | | | | |

|include: Contacts during school registration, attendance at PTA | |Interview Staff | | | | |

|meetings, mailings, notes to parents, intercom announcements, | |Marketing, flyers, | | | | |

|bulletin boards, posters, student newspapers/newsletters, | |brochures, etc | | | | |

|workshops for teachers and school staff, radio, TV, videos, open | | | | | | |

|house, contacts center/school newsletters. | | | | | | |

| | | | | | | |

|Clinic enrollment trend. | | | | | | |

| | | | | | | |

| | | | | | | |

|Accessibility to Services |2200.80 A-J |Observation | | | | |

|Hours of services are available to the patient | |Interview Staff | | | | |

|24 hour access to services | | | | | | |

|Bilingual services available | | | | | | |

|Convenient parking | | | | | | |

|Access for the physically challenged | | | | | | |

| | | | | | | |

|Patient Risk Minimization |2200.40 |Exposure Control Plan | | | | |

|Written exposure control plan |2200.50 |P&P | | | | |

|Handling and sterilization of reusable equipment |2200.80 |Interview Staff | | | | |

|Disinfection of contaminated patient care areas |2 A-C | | | | | |

| |2200.80, b,2 | | | | | |

| | | | | | | |

|Other Review Activities |

|Number of charts reviewed | |

|Methods of random selection | |

|Staffing update | |

|Barriers to service delivery | |

|Education needs of staff | |

|Observation of clinic flow | |

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|SCHOOL BASED HEALTH CENTER EVALUATION PROTOCOL |

|Corrective Action Plan |

|Please respond to the following required actions by: ____________________________________________ |

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