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] | | | | | | | |
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