Reviewer: - Illinois Department of Human Services



|ILLINOIS DEPARTMENT OF HUMAN SERVICES |

|Bureau of Community Health Nursing |

|School Based-Linked Health Center Clinical Review Collection Tool FY13 |

|Date: | |Response Codes: Present = X | |

|Center: | | |Absent = O | |

|MCH Nurse Consultant: | | |Not Applicable = N/A | |

|Client’s Medical Record Number | | | | | |Totals |

| | | | | | |X |O |

|Number of visits = 3 or more | | | | | | | |

|Intake | | | | | | | |

|Name, sex, age, address, race, ethnicity | | | | | | | |

| Date care initiated | | | | | | | |

| Eligibility Status Determined | | | | | | | |

| Consent for Treatment Present | | | | | | | |

| Release of Information | | | | | | | |

|Medical Record | | | | | | | |

| Individual Medical Record | | | | | | | |

| Student’s name and identifying # on each page of record | | | | | | | |

| Entries are all dated and signed by provider | | | | | | | |

| Current services relate to diagnosis/health maintenance | | | | | | | |

| Coordination of Medical care | | | | | | | |

| Problem List present and current | | | | | | | |

| Medication Sheet present & current | | | | | | | |

| Allergies | | | | | | | |

| Global Risk or Developmental Assessment | | | | | | | |

|completed by 3rd visit (n/a if less than 3 visits) | | | | | | | |

| Global Risk or Developmental Assessment | | | | | | | |

|updated annually. | | | | | | | |

|Family History Completed | | | | | | | |

|Nutritional History Completed | | | | | | | |

|Medical History Completed | | | | | | | |

|Social History Completed Includes the following: | | | | | | | |

| |Alcohol | | | | | | |

|Client’s Medical Record Number | | | | | |Totals |

| | | | | | |X |O |

| Mental Health Services | | | | | | | |

| Immunization History | | | | | | | |

| Vital signs documented each visit | | | | | | | |

| Height/Weight | | | | | | | |

| BMI documented | | | | | | | |

|Risk identified | | | | | | | |

|Address if > 85th percentile | | | | | | | |

| Chief Complaint | | | | | | | |

| Physical Exam for each visit (full focused physical | | | | | | | |

|exam) | | | | | | | |

| Treatment Plan for each visit | | | | | | | |

| Appropriate referrals are made and follow up | | | | | | | |

|demonstrated | | | | | | | |

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

| Dental | | | | | | | |

| Vision/Hearing screens | | | | | | | |

| Reproductive health issues addressed | | | | | | | |

|Hx of sexual activity | | | | | | | |

|Abstinence Counseling | | | | | | | |

|CH/GC screening & counseling | | | | | | | |

|Timeliness to treatment | | | | | | | |

|Diagnosis & Treatment of STIs | | | | | | | |

|Family Planning methods counseling | | | | | | | |

|Informed of method specific risks and side | | | | | | | |

|effects | | | | | | | |

|Method specific consent signed | | | | | | | |

|Pregnancy Testing & Counseling | | | | | | | |

|Prenatal Care/Postnatal Care | | | | | | | |

| Laboratory Tests & Screens | | | | | | | |

|Routine: HGB/HCT, UA | | | | | | | |

|STI Tests (RPR, wet mount, other) | | | | | | | |

|Other: TB test, Lead, Blood Glucose, Lipids, PFT, EPDS, | | | | | | | |

|Peak Flow [list] | | | | | | | |

COMMENTS:

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