Chart Review Tool - Michigan



chart review toolMichigan Department of Health and Human ServicesMaternal Infant Health ProgramBENEFICIARY NameDate First Contacted or Visited FORMTEXT ????? FORMTEXT ?????FORMS CHECKLIST (5700/5701)Beneficiary Name PresentDate Referral to MIHP ReceivedContacted w/in Appropriate Days* FORMCHECKBOX Yes FORMCHECKBOX No FORMTEXT ????? FORMCHECKBOX Yes FORMCHECKBOX NoAlterations Done Inappropriately FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX NANotes FORMTEXT ?????CONTACT LOG (5649)MIHP Agency Name PresentBeneficiary Name PresentAlterations Done Inappropriately FORMCHECKBOX Yes FORMCHECKBOX No (Not Required) FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX NANotes FORMTEXT ?????CONSENT TO PARTICIPATE (5647/5652)MIHP Agency Name PresentConsent to Participate in Risk Identifier Checked (one box) FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX NoConsent to Participate in MIHP Checked (one box)Beneficiary/Legal Representative Signature Section Complete and Accurate** FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX NoProfessional Signature Section Complete and Accurate**Date of Beneficiary/Legal Representative Signature FORMCHECKBOX Yes FORMCHECKBOX No FORMTEXT ?????Dated on or before RIAlterations Done Incorrectly FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX NANotes FORMTEXT ?????CONSENT TO RELEASE PHI (5653/5645)MIHP Agency Name PresentAll Necessary Dates & InitialsConsent to Release PHI Checked (one box) FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX NoBeneficiary/Legal Representative Signature Section Complete and Accurate** FORMCHECKBOX Yes FORMCHECKBOX NoProfessional Signature Section Complete and Accurate**Consented to Communication w/Medical Provider re: Infant FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX NoConsented to Communication w/Medical Provider re: CaregiverAlterations Done Incorrectly FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX NA FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX NANotes FORMTEXT ?????RISK IDENTIFIERPresentRI Screening DateProfession Conducted RI FORMCHECKBOX Yes FORMCHECKBOX No FORMTEXT ????? FORMCHECKBOX RN FORMCHECKBOX LSW FORMCHECKBOX NeitherCompleted Prior to any Professional Visit FORMCHECKBOX Yes FORMCHECKBOX NoIf RI not Completed Prior to any Professional Visit, Emergency Documented on PVPN or Contact Log FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX NAAlterations Done Incorrectly FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX NANotes FORMTEXT ?????RISK IDENTIFIER SCORESHEETRisk Levels MarkedIf no Risk Identified, Exception Approval PresentAlterations Done Incorrectly FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX NA FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX NANotes FORMTEXT ?????PLAN OF CARE, PART 1 [5637/5642]Beneficiary Name PresentActivity #5 (one box checked) FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX NoActivity #11 (one box checked)Activity #14 Entry (one or more item listed) FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX NoProfessional Signature Section Complete and Accurate**Alterations Done Incorrectly FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX NANotes FORMTEXT ?????PLAN OF CARE, PART 2 [5690-5696/5630-5632, 5665, 5665-5667, 5669, 5670, 5672-5675]POC 2 Domains from RI Scoresheet PresentUnknown Risk Levels from RI Scoresheet are Marked Highest Possible Level on POC 2 FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX NAIf Risk Level Changed, New Intervention Level CheckedIf Risk Level Changed, Date of Change Documented FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX NA FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX NAIf Domains Added Based on Professional Judgement, Date of Addition PresentAlterations Done Incorrectly FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX NA FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX NANotes FORMTEXT ?????PLAN OF CARE, PART 3 [5697/5676]Beneficiary Name PresentCase Manager Name PresentReassigned Case Manager Name Present FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX NARN and LSW Signatures within 10 Business DaysBoth Professionals Signatures are Dated Prior to any Professional Visit FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX NoIf Professional Visit Occurred Prior to Signature Dates, Emergency Documented on PVPN or Contact Log FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX NARN/LSW Updated Signatures within 10 Business Days when POC 2 AddedAlterations Done Incorrectly FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX NA FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX NANotes FORMTEXT ?????COMMUNICATION WITH MEDICAL PROVIDERProvider Communicated with Medical Provider re: BeneficiaryFollowed Consent re: Beneficiary FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX NoProvider Communicated with Medical Provider re: CaregiverFollowed Consent re: Caregiver FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX NA FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX NANotes FORMTEXT ?????BENEFICIARY STATUS NOTIFICATION AT ENROLLMENT (5640)Present at EnrollmentBeneficiary Info Section Complete and Accurate** FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX NoCheckbox Section Complete and Accurate**Staff Info Section Complete and Accurate** FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX NoSent within 14 Calendar Days of Risk Identifier DateAlterations Done Incorrectly FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX NANotes FORMTEXT ?????COMMUNICATION FORM (5638/5639)Communication Form PresentBeneficiary Info Section Complete and Accurate** FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX NoRI Score Summary Matches POC 2 from RIProfessional Signature Section Complete and Accurate** FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX NoAlterations Done Incorrectly FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX NANotes FORMTEXT ?????BENEFICIARY STATUS NOTIFICATION AT TRANSFER (5640) FORMCHECKBOX NAPresent at TransferBeneficiary Info Section Complete and Accurate** FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX NA FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX NACheckbox Section Complete and Accurate**Staff Info Section Complete and Accurate** FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX NA FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX NASent within 14 Calendar Days of TransferAlterations Done Incorrectly FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX NA FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX NANotes FORMTEXT ?????BENEFICIARY STATUS NOTIFICATION AT DISCHARGE (5640)Present at DischargeBeneficiary Info Section Complete and Accurate** FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX NA FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX NACheckbox Section Complete and Accurate**“Discharge Summary Attached” Checked FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX NA FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX NAStaff Info Section Complete and Accurate**Sent within 14 Calendar Days of Discharge Summary Date FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX NA FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX NAAlterations Done Incorrectly FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX NANotes FORMTEXT ?????BENEFICIARY TRANSFER (5646, 5699/5646, 5708) FORMCHECKBOX NAConsent to Transfer MIHP Records PresentBoth Providers Listed FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX NA FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX NAHealth Info Checkbox (one or more boxes checked)Consent Checkbox (one checked) FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX NA FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX NABeneficiary Info Section Complete and Accurate**Professional Info Section Complete and Accurate** FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX NA FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX NAAlterations Done IncorrectlyTransfer Checklist Present FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX NA FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX NAAlterations Done IncorrectlyDocuments Received Prior to First Professional Visit FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX NA FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX NAIf First Professional Visit Done Prior to Documents Being Received, Emergency Documented on PVPN or Contact Log FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX NANotes FORMTEXT ?????DISCHARGE SUMMARY Infant: 18 Month BirthdayMaternal: 60th Day PostpartumDate of Discharge Summary FORMTEXT ????? FORMCHECKBOX NA FORMTEXT ????? FORMCHECKBOX NA FORMTEXT ????? FORMCHECKBOX NAInfant: Completed within 30 Days of 18 Month BirthdayMaternal: Completed 30 days after End of Month in which 60th Day Postpartum Falls FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX NA FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX NAAlterations Done IncorrectlyInfant: Visits Continued Past 18 Months FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX NA FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX NAInfant: Authorized to Continue Past 18 Months FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX NANotes FORMTEXT ?????NOTIFICATION OF MULTIPLE CHARTS OPEN (5704)PresentAll Beneficiaries IdentifiedAlterations Done Incorrectly FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX NA FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX NA FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX NAInfant: Part of Multiple BirthInfant: IRI Present for Sibling(s)Infant: POC 2 Present for Sibling(s) FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX NA FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX NA FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX NAInfant: POC 3 Present for Sibling(s)Infant: Discharge Summary Present for Sibling(s) FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX NA FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX NANotes FORMTEXT ?????MCIRDate MCIR PulledInfant: Date Infant Turned 5 Months Old FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX NAInfant: Pulled for Visit at 5 Months Old or Subsequent Visit FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX NAIf Infant MCIR not pulled in appropriate timeframe, reason documented on PVPN or Contact Log FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX NAMaternal: Pulled While EnrolledIf Maternal MCIR not pulled, reason documented on Contact Log FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX NA FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX NAAlterations Done Incorrectly FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX NANotes FORMTEXT ?????PROFESSIONAL VISIT PROGRESS NOTE REVIEWBeneficiary Domains Present in POC 2Risk LevelVisit Number First AddressedInfant Domains FORMCHECKBOX Family and Social Support FORMCHECKBOX Moderate FORMTEXT ????? FORMCHECKBOX Infant Health Care FORMCHECKBOX Low FORMCHECKBOX Moderate FORMCHECKBOX High FORMTEXT ????? FORMCHECKBOX Infant Safety FORMCHECKBOX High FORMTEXT ????? FORMCHECKBOX Infant Feeding FORMCHECKBOX Moderate FORMCHECKBOX High FORMTEXT ????? FORMCHECKBOX General Infant Development FORMCHECKBOX Moderate FORMTEXT ????? FORMCHECKBOX Substance Exposed Infant FORMCHECKBOX Low FORMCHECKBOX Moderate FORMCHECKBOX High FORMTEXT ????? FORMCHECKBOX Infant Breastfeeding FORMCHECKBOX Moderate FORMCHECKBOX High FORMTEXT ?????Maternal Domains FORMCHECKBOX Pregnancy Health FORMCHECKBOX Moderate FORMCHECKBOX High FORMTEXT ????? FORMCHECKBOX Medical Considerations FORMCHECKBOX Low FORMCHECKBOX Moderate FORMTEXT ????? FORMCHECKBOX Family Planning FORMCHECKBOX Low FORMCHECKBOX Moderate FORMTEXT ????? FORMCHECKBOX Food/Nutrition FORMCHECKBOX Low FORMCHECKBOX Moderate FORMCHECKBOX High FORMTEXT ????? FORMCHECKBOX Tobacco FORMCHECKBOX Moderate FORMTEXT ????? FORMCHECKBOX Alcohol FORMCHECKBOX Moderate FORMCHECKBOX High FORMTEXT ????? FORMCHECKBOX Substance Misuse FORMCHECKBOX Moderate FORMCHECKBOX High FORMTEXT ????? FORMCHECKBOX Stress/Depression FORMCHECKBOX Low FORMCHECKBOX Moderate FORMCHECKBOX High FORMTEXT ????? FORMCHECKBOX Social Support FORMCHECKBOX Moderate FORMTEXT ????? FORMCHECKBOX Abuse/Violence FORMCHECKBOX Moderate FORMCHECKBOX High FORMTEXT ????? FORMCHECKBOX Housing FORMCHECKBOX Moderate FORMCHECKBOX High FORMTEXT ????? FORMCHECKBOX Transportation FORMCHECKBOX Moderate FORMTEXT ????? FORMCHECKBOX Breastfeeding FORMCHECKBOX Low FORMCHECKBOX Moderate FORMCHECKBOX High FORMTEXT ?????Safety Plan Required and Intervention Number Safety Plan Intervention DocumentedStress/Depression#13 FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX NoAbuse/Violence#12 FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX NoSubstance Exposed Infant#9 FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX NoInfant Safety#6 FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX NoReferral Topic: List Below (Include those Initiated at Assessment Visit)Visit Number Initiated (Assessment Visit=0)Follow Up Visit NumberIf Follow Up Did Not Occur within 3 Visits, Reason Documented on PVPN or Contact Log FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX NA FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX NA FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX NA FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX NA FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX NA FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX NA FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX NA FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX NA FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX NA FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX NA FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX NAPROFESSIONAL VISIT PROGRESS NOTE #1DateBeneficiary Info Section Complete and Accurate** FORMTEXT ????? FORMCHECKBOX Yes FORMCHECKBOX NoVisit Last 30+ MinutesIf a Community Visit, Reason Documented FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX NAContent Addressed FORMCHECKBOX Plan of Care Domain FORMCHECKBOX Beneficiary Concern FORMCHECKBOX Professional JudgementBeneficiary Reaction to Intervention Provided CompleteChecklist Section Complete FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX NA FORMCHECKBOX Yes FORMCHECKBOX NoAction Plan Checked Beneficiary Feedback and Desired Plan for Next Visit Complete FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX NoSpecific Plan for Next Visit - Staff CompleteProfessional Info Section Complete and Accurate** FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX NoProfession Completing Visit FORMCHECKBOX RN FORMCHECKBOX LSW FORMCHECKBOX RD FORMCHECKBOX OtherNotes FORMTEXT ?????PROFESSIONAL VISIT PROGRESS NOTE #2DateBeneficiary Info Section Complete and Accurate** FORMTEXT ????? FORMCHECKBOX Yes FORMCHECKBOX NoVisit Last 30+ MinutesIf a Community Visit, Reason Documented FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX NAContent Addressed FORMCHECKBOX Plan of Care Domain FORMCHECKBOX Beneficiary Concern FORMCHECKBOX Professional JudgementBeneficiary Reaction to Intervention Provided CompleteChecklist Section Complete FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX NA FORMCHECKBOX Yes FORMCHECKBOX NoAction Plan Checked Beneficiary Feedback and Desired Plan for Next Visit Complete FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX NoSpecific Plan for Next Visit - Staff CompleteProfessional Info Section Complete and Accurate** FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX NoProfession Completing Visit FORMCHECKBOX RN FORMCHECKBOX LSW FORMCHECKBOX RD FORMCHECKBOX OtherNotes FORMTEXT ?????PROFESSIONAL VISIT PROGRESS NOTE #3DateBeneficiary Info Section Complete and Accurate** FORMTEXT ????? FORMCHECKBOX Yes FORMCHECKBOX NoVisit Last 30+ MinutesIf a Community Visit, Reason Documented FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX NAContent Addressed FORMCHECKBOX Plan of Care Domain FORMCHECKBOX Beneficiary Concern FORMCHECKBOX Professional JudgementBeneficiary Reaction to Intervention Provided CompleteChecklist Section Complete FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX NA FORMCHECKBOX Yes FORMCHECKBOX NoAction Plan Checked Beneficiary Feedback and Desired Plan for Next Visit Complete FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX NoSpecific Plan for Next Visit - Staff CompleteProfessional Info Section Complete and Accurate** FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX NoProfession Completing VisitAll High Risk Domains Addressed FORMCHECKBOX RN FORMCHECKBOX LSW FORMCHECKBOX RD FORMCHECKBOX Other FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX NAIf All High Risk Domains Have Not Been Addressed, Reason Documented on PVPN or Contact Log FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX NANotes FORMTEXT ?????PROFESSIONAL VISIT PROGRESS NOTE #4DateBeneficiary Info Section Complete and Accurate** FORMTEXT ????? FORMCHECKBOX Yes FORMCHECKBOX NoVisit Last 30+ MinutesIf a Community Visit, Reason Documented FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX NAContent Addressed FORMCHECKBOX Plan of Care Domain FORMCHECKBOX Beneficiary Concern FORMCHECKBOX Professional JudgementBeneficiary Reaction to Intervention Provided CompleteChecklist Section Complete FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX NA FORMCHECKBOX Yes FORMCHECKBOX NoAction Plan Checked Beneficiary Feedback and Desired Plan for Next Visit Complete FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX NoSpecific Plan for Next Visit - Staff CompleteProfessional Info Section Complete and Accurate** FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX NoProfession Completing Visit FORMCHECKBOX RN FORMCHECKBOX LSW FORMCHECKBOX RD FORMCHECKBOX OtherNotes FORMTEXT ?????PROFESSIONAL VISIT PROGRESS NOTE #5DateBeneficiary Info Section Complete and Accurate** FORMTEXT ????? FORMCHECKBOX Yes FORMCHECKBOX NoVisit Last 30+ MinutesIf a Community Visit, Reason Documented FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX NAContent Addressed FORMCHECKBOX Plan of Care Domain FORMCHECKBOX Beneficiary Concern FORMCHECKBOX Professional JudgementBeneficiary Reaction to Intervention Provided CompleteChecklist Section Complete FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX NA FORMCHECKBOX Yes FORMCHECKBOX NoAction Plan Checked Beneficiary Feedback and Desired Plan for Next Visit Complete FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX NoSpecific Plan for Next Visit - Staff CompleteProfessional Info Section Complete and Accurate** FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX NoProfession Completing Visit FORMCHECKBOX RN FORMCHECKBOX LSW FORMCHECKBOX RD FORMCHECKBOX OtherNotes FORMTEXT ?????REQUIRED DISCIPLINESRN & LSW Both Conducted a VisitIf Not, Reason Documented on Contact Log FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX NANotes FORMTEXT ?????PLAN OF CARE, 2All Domains Addressed Prior to DischargeIf Not, Reason Documented on Contact Log FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX NANotes FORMTEXT ?????MATERNAL HOME VISITSHome Visit Occurred During PregnancyIf Not, Reason Documented on Contact Log FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX NA FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX NAHome Visit Occurred PostpartumIf Not, Reason Documented on Contact Log FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX NA FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX NANotes FORMTEXT ?????SAFETY PLANIf Safety Plan Required, Intervention DocumentedIf Required and not Documented, Reason Documented on Contact Log FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX NA FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX NANotes FORMTEXT ?????ACTION PLANAction Plan is Documented (checkbox)If not Documented, Reason Documented on Contact Log FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX NANotes FORMTEXT ?????STRESS/DEPRESSION REFERRALIf Stress/Depression Domain Present in POC 2, Referral DocumentedIf Referral Not Documented, Reason Documented on Contact Log FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX NA FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX NANotes FORMTEXT ?????REGISTERED DIETICIAN REFERRALFood/Nutrition Domain Present and High RiskIf Yes, Internal RD Conducted a Visit or RD Referral Documented FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX NAIf RD Did not Conduct a Visit and No RD Referral Occurred, Reason Documented on Contact Log FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX NANotes FORMTEXT ?????MATERNAL-ONLY PROVIDER: INFANT MIHP REFERRALReferral to Infant MIHP Provider Documented FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX NANotes FORMTEXT ?????PHYSICIAN ORDER: RD SERVICESRD Conducted a Professional VisitOrder for RD Services Present in Chart FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX NAMIHP Provider Name Present on OrderMedical Provider Contact Info Present on Order FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX NA FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX NAMedical Provider Signature, Credentials, Date Present on OrderRationale Present FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX NA FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX NANotesPHYSICIAN ORDER: MORE THAN 9 VISITS FORMCHECKBOX NAMore than 9 Visits ConductedOrder for Additional Visit Present in Chart FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX NAMIHP Provider Name Present on OrderMedical Provider Contact Info Present on Order FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX NA FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX NAMedical Provider Signature, Credentials, Date Present on OrderRationale Present FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX NA FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX NANotes FORMTEXT ?????PHYSICIAN ORDER: MORE THAN 18 VISITS FORMCHECKBOX NAMore than 18 Visits ConductedOrder for Additional Visit Present in Chart FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX NAMIHP Provider Name Present on OrderMedical Provider Contact Info Present on Order FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX NA FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX NAMedical Provider Signature, Credentials, Date Present on OrderRationale Present FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX NA FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX NANotes FORMTEXT ?????DEVELOPMENTAL SCREENING REVIEW FORMCHECKBOX NABirth DateGestational Age FORMTEXT ????? FORMTEXT ?????BRIGHT FUTURESDate Conducted“Not Yet” Present FORMTEXT ????? FORMCHECKBOX Yes FORMCHECKBOX NoType of Screening Required for Follow-up (Bright Futures required for infants less than 1 month) FORMCHECKBOX Bright Futures FORMCHECKBOX ASQ-3Notes FORMTEXT ?????Bright Futures Follow Up ConductedDate Conducted FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX NA FORMTEXT ?????Correct Screener Used"Not Yet" Present FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX NA FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX NANotes FORMTEXT ?????ASQ-3Date of First VisitDate of First ASQ-3 FORMTEXT ????? FORMTEXT ?????Reason Not Completed at First Visit DocumentedCorrect Screener Used FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX NA FORMCHECKBOX Yes FORMCHECKBOX NoInformation Summary Complete and Accurate**Outcome FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX White FORMCHECKBOX Grey FORMCHECKBOX BlackReferral PresentOutcome of Referral FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX NA FORMCHECKBOX Enrolled FORMCHECKBOX Declined FORMCHECKBOX Didn’t Qualify FORMCHECKBOX In ProgressLearning Materials ProvidedRescreen Requirement FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX NA FORMCHECKBOX 4 months FORMCHECKBOX 2 months FORMCHECKBOX NANotes FORMTEXT ?????Date of Second ASQ-3Reason Not CompletedCorrect Screener Used FORMTEXT ????? FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX NA FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX NAInformation Summary Complete and Accurate**Outcome FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX White FORMCHECKBOX Grey FORMCHECKBOX BlackReferral PresentOutcome of Referral FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX NA FORMCHECKBOX Enrolled FORMCHECKBOX Declined FORMCHECKBOX Didn’t Qualify FORMCHECKBOX In ProgressLearning Materials ProvidedRescreen Requirement FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX NA FORMCHECKBOX 4 months FORMCHECKBOX 2 months FORMCHECKBOX NANotes FORMTEXT ?????Date of Third ASQ-3Reason Not CompletedCorrect Screener Used FORMTEXT ????? FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX NA FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX NAInformation Summary Complete and Accurate**Outcome FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX White FORMCHECKBOX Grey FORMCHECKBOX BlackReferral PresentOutcome of Referral FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX NA FORMCHECKBOX Enrolled FORMCHECKBOX Declined FORMCHECKBOX Didn’t Qualify FORMCHECKBOX In ProgressLearning Materials ProvidedRescreen Requirement FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX NA FORMCHECKBOX 4 months FORMCHECKBOX 2 months FORMCHECKBOX NANotes FORMTEXT ?????Date of Fourth ASQ-3Reason Not CompletedCorrect Screener Used FORMTEXT ????? FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX NA FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX NAInformation Summary Complete and Accurate**Outcome FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX White FORMCHECKBOX Grey FORMCHECKBOX BlackReferral PresentOutcome of Referral FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX NA FORMCHECKBOX Enrolled FORMCHECKBOX Declined FORMCHECKBOX Didn’t Qualify FORMCHECKBOX In ProgressLearning Materials ProvidedRescreen Requirement FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX NA FORMCHECKBOX 4 months FORMCHECKBOX 2 months FORMCHECKBOX NANotes FORMTEXT ?????Date of Fifth ASQ-3Reason Not CompletedCorrect Screener Used FORMTEXT ????? FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX NA FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX NAInformation Summary Complete and Accurate**Outcome FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX White FORMCHECKBOX Grey FORMCHECKBOX BlackReferral PresentOutcome of Referral FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX NA FORMCHECKBOX Enrolled FORMCHECKBOX Declined FORMCHECKBOX Didn’t Qualify FORMCHECKBOX In ProgressLearning Materials ProvidedRescreen Requirement FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX NA FORMCHECKBOX 4 months FORMCHECKBOX 2 months FORMCHECKBOX NANotes FORMTEXT ?????ASQ: SE-22 Month Tool CompletedDate of Completion FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX NA FORMTEXT ?????Reason Not Completed, Documented on PVPN or Contact Log FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX NAIn Correct Timeframe (1 month, 0 days – 2 months, 30 days) FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX NAInformation Summary Complete and Accurate**Outcome FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX NA FORMCHECKBOX White FORMCHECKBOX Grey FORMCHECKBOX Black FORMCHECKBOX NAReferral PresentOutcome of Referral FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX NA FORMCHECKBOX Enrolled FORMCHECKBOX Declined FORMCHECKBOX Didn’t Qualify FORMCHECKBOX In ProgressLearning Materials Provided FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX NANotes FORMTEXT ?????6 Month Tool CompletedDate of Completion FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX NA FORMTEXT ?????Reason Not Completed, Documented on PVPN or Contact Log FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX NAIn Correct Timeframe (3 months, 0 days – 8 months, 30 days) FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX NAInformation Summary Complete and Accurate**Outcome FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX NA FORMCHECKBOX White FORMCHECKBOX Grey FORMCHECKBOX Black FORMCHECKBOX NAReferral PresentOutcome of Referral FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX NA FORMCHECKBOX Enrolled FORMCHECKBOX Declined FORMCHECKBOX Didn’t Qualify FORMCHECKBOX In ProgressLearning Materials Provided FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX NANotes FORMTEXT ?????12 Month Tool CompletedDate of Completion FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX NA FORMTEXT ?????Reason Not Completed, Documented on PVPN or Contact Log FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX NAIn Correct Timeframe (9 months, 0 days – 14 months, 30 days) FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX NAInformation Summary Complete and Accurate**Outcome FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX NA FORMCHECKBOX White FORMCHECKBOX Grey FORMCHECKBOX Black FORMCHECKBOX NAReferral PresentOutcome of Referral FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX NA FORMCHECKBOX Enrolled FORMCHECKBOX Declined FORMCHECKBOX Didn’t Qualify FORMCHECKBOX In ProgressLearning Materials Provided FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX NANotes FORMTEXT ?????18 Month Tool CompletedDate of Completion FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX NA FORMTEXT ?????Reason Not Completed, Documented on PVPN or Contact Log FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX NAIn Correct Timeframe (15 months, 0 days – 20 months, 30 days) FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX NAInformation Summary Complete and Accurate**Outcome FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX NA FORMCHECKBOX White FORMCHECKBOX Grey FORMCHECKBOX Black FORMCHECKBOX NAReferral PresentOutcome of Referral FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX NA FORMCHECKBOX Enrolled FORMCHECKBOX Declined FORMCHECKBOX Didn’t Qualify FORMCHECKBOX In ProgressLearning Materials Provided FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX NANotes FORMTEXT ?????*See Operations Guide for specifics**Complete and Accurate: all data elements are present and information is accurateAlterations: NA indicates no alterations were made. ................
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