Triennial Review Tool - Title Here
Nurse-Family Partnership Records ReviewLocal Public Health Authority (LPHA): FORMTEXT ?????Reviewer: FORMTEXT ?????Administrator: FORMTEXT ?????Participants: FORMTEXT ?????Date(s) of review (mm/dd/yyyy): FORMTEXT ?????Date of report (mm/dd/yyyy): FORMTEXT ?????Mother chart identifierChild chart identifier FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Demographics and service coordinationClient name OAR 410-138-0007 FORMTEXT ??? FORMTEXT ??? FORMTEXT ??? FORMTEXT ??? FORMTEXT ??? FORMTEXT ??? FORMTEXT ??? FORMTEXT ??? FORMTEXT ??? FORMTEXT ??? FORMTEXT ??? FORMTEXT ???Birth date (QA) FORMTEXT ??? FORMTEXT ??? FORMTEXT ??? FORMTEXT ??? FORMTEXT ??? FORMTEXT ??? FORMTEXT ??? FORMTEXT ??? FORMTEXT ??? FORMTEXT ??? FORMTEXT ??? FORMTEXT ???Estimated date of delivery (EDD) FORMTEXT ??? FORMTEXT ??? FORMTEXT ??? FORMTEXT ??? FORMTEXT ??? FORMTEXT ???Address (QA) FORMTEXT ??? FORMTEXT ??? FORMTEXT ??? FORMTEXT ??? FORMTEXT ??? FORMTEXT ??? FORMTEXT ??? FORMTEXT ??? FORMTEXT ??? FORMTEXT ??? FORMTEXT ??? FORMTEXT ???Phone number (QA) FORMTEXT ??? FORMTEXT ??? FORMTEXT ??? FORMTEXT ??? FORMTEXT ??? FORMTEXT ??? FORMTEXT ??? FORMTEXT ??? FORMTEXT ??? FORMTEXT ??? FORMTEXT ??? FORMTEXT ???Health care provider name and phone number (QA) FORMTEXT ??? FORMTEXT ??? FORMTEXT ??? FORMTEXT ??? FORMTEXT ??? FORMTEXT ??? FORMTEXT ??? FORMTEXT ??? FORMTEXT ??? FORMTEXT ??? FORMTEXT ??? FORMTEXT ???Other agencies serving, contact names and phone numbers. OAR 410-138-0007 FORMTEXT ??? FORMTEXT ??? FORMTEXT ??? FORMTEXT ??? FORMTEXT ??? FORMTEXT ??? FORMTEXT ??? FORMTEXT ??? FORMTEXT ??? FORMTEXT ??? FORMTEXT ??? FORMTEXT ???Parents’ names and address (QA) FORMTEXT ??? FORMTEXT ??? FORMTEXT ??? FORMTEXT ??? FORMTEXT ??? FORMTEXT ???Referral source and reason for referral (QA) FORMTEXT ??? FORMTEXT ??? FORMTEXT ??? FORMTEXT ??? FORMTEXT ??? FORMTEXT ???Evidence of referral feedback to referent in record (QA) FORMTEXT ??? FORMTEXT ??? FORMTEXT ??? FORMTEXT ??? FORMTEXT ??? FORMTEXT ???Nursing DocumentationNursing Assessment documented. OAR 851-045-0060 (2) FORMTEXT ??? FORMTEXT ??? FORMTEXT ??? FORMTEXT ??? FORMTEXT ??? FORMTEXT ??? FORMTEXT ??? FORMTEXT ??? FORMTEXT ??? FORMTEXT ??? FORMTEXT ??? FORMTEXT ???Subjective data documented (concise, pertinent description of situation) OAR 851-045-0060 (2) FORMTEXT ??? FORMTEXT ??? FORMTEXT ??? FORMTEXT ??? FORMTEXT ??? FORMTEXT ??? FORMTEXT ??? FORMTEXT ??? FORMTEXT ??? FORMTEXT ??? FORMTEXT ??? FORMTEXT ???Objective data documented (factual information that may include laboratory data, positive and/or negative physical findings, or descriptions of observed client behaviors) (Compliance issue) OAR 851-045-0060 (2) FORMTEXT ??? FORMTEXT ??? FORMTEXT ??? FORMTEXT ??? FORMTEXT ??? FORMTEXT ??? FORMTEXT ??? FORMTEXT ??? FORMTEXT ??? FORMTEXT ??? FORMTEXT ??? FORMTEXT ???Objective Data includes:Maternal blood pressure at every visit during perinatal period (PN–6 weeks PP). OAR 851-045-0060 (2) FORMTEXT ??? FORMTEXT ??? FORMTEXT ??? FORMTEXT ??? FORMTEXT ??? FORMTEXT ???Prenatal height and weight documented at initial visit and weight gain plotted on appropriate grid. OAR 410-138-0060 (11) (c), OAR 851-045-0060 (2) FORMTEXT ??? FORMTEXT ??? FORMTEXT ??? FORMTEXT ??? FORMTEXT ??? FORMTEXT ???Child Growth Grids (height, weight and head circumference consistently documented, and ratios plotted) OAR 410-138-0060 (11) (c), OAR 851-045-0060 (2) FORMTEXT ??? FORMTEXT ??? FORMTEXT ??? FORMTEXT ??? FORMTEXT ??? FORMTEXT ???Subsequent pregnancy intention and contraception need assessed in 3rd trimester. FORMTEXT ??? FORMTEXT ??? FORMTEXT ??? FORMTEXT ??? FORMTEXT ??? FORMTEXT ???NFP Screening & Assessment Tools: Administered according to schedule; tools are scored (STAR, PHQ-9, Health Habits, DANCE). NFP Contract Model Element 10. FORMTEXT ??? FORMTEXT ??? FORMTEXT ??? FORMTEXT ??? FORMTEXT ??? FORMTEXT ??? FORMTEXT ??? FORMTEXT ??? FORMTEXT ??? FORMTEXT ??? FORMTEXT ??? FORMTEXT ???STAR FORMTEXT ??? FORMTEXT ??? FORMTEXT ??? FORMTEXT ??? FORMTEXT ??? FORMTEXT ??? PHQ-9 FORMTEXT ??? FORMTEXT ??? FORMTEXT ??? FORMTEXT ??? FORMTEXT ??? FORMTEXT ???GAD-7 (optional, QA only) FORMTEXT ??? FORMTEXT ??? FORMTEXT ??? FORMTEXT ??? FORMTEXT ??? FORMTEXT ???Health Habits FORMTEXT ??? FORMTEXT ??? FORMTEXT ??? FORMTEXT ??? FORMTEXT ??? FORMTEXT ???Clinical IPV Assessment FORMTEXT ??? FORMTEXT ??? FORMTEXT ??? FORMTEXT ??? FORMTEXT ??? FORMTEXT ???DANCE FORMTEXT ??? FORMTEXT ??? FORMTEXT ??? FORMTEXT ??? FORMTEXT ??? FORMTEXT ??? FORMTEXT ??? FORMTEXT ??? FORMTEXT ??? FORMTEXT ??? FORMTEXT ??? FORMTEXT ???M-CHAT (optional, QA only) FORMTEXT ??? FORMTEXT ??? FORMTEXT ??? FORMTEXT ??? FORMTEXT ??? FORMTEXT ???ASQ FORMTEXT ??? FORMTEXT ??? FORMTEXT ??? FORMTEXT ??? FORMTEXT ??? FORMTEXT ???ASQ-SE FORMTEXT ??? FORMTEXT ??? FORMTEXT ??? FORMTEXT ??? FORMTEXT ??? FORMTEXT ???NFP Visit Form (see 12. below) FORMTEXT ??? FORMTEXT ??? FORMTEXT ??? FORMTEXT ??? FORMTEXT ??? FORMTEXT ??? FORMTEXT ??? FORMTEXT ??? FORMTEXT ??? FORMTEXT ??? FORMTEXT ??? FORMTEXT ???MIECHV Data Requirements (MIECHV sites only) FORMTEXT ??? FORMTEXT ??? FORMTEXT ??? FORMTEXT ??? FORMTEXT ??? FORMTEXT ??? FORMTEXT ??? FORMTEXT ??? FORMTEXT ??? FORMTEXT ??? FORMTEXT ??? FORMTEXT ???Nursing diagnosis or client problem and strengths documented OAR 851-045-0060 (2) FORMTEXT ??? FORMTEXT ??? FORMTEXT ??? FORMTEXT ??? FORMTEXT ??? FORMTEXT ??? FORMTEXT ??? FORMTEXT ??? FORMTEXT ??? FORMTEXT ??? FORMTEXT ??? FORMTEXT ???Integration and analysis of subjective and objective data that distinguishes normal from abnormal data. FORMTEXT ??? FORMTEXT ??? FORMTEXT ??? FORMTEXT ??? FORMTEXT ??? FORMTEXT ??? FORMTEXT ??? FORMTEXT ??? FORMTEXT ??? FORMTEXT ??? FORMTEXT ??? FORMTEXT ???Identification of client areas of strength, problem or risk based on assessment. FORMTEXT ??? FORMTEXT ??? FORMTEXT ??? FORMTEXT ??? FORMTEXT ??? FORMTEXT ??? FORMTEXT ??? FORMTEXT ??? FORMTEXT ??? FORMTEXT ??? FORMTEXT ??? FORMTEXT ???Nursing Care Plan established. OAR 851-045-0060 (2) FORMTEXT ??? FORMTEXT ??? FORMTEXT ??? FORMTEXT ??? FORMTEXT ??? FORMTEXT ??? FORMTEXT ??? FORMTEXT ??? FORMTEXT ??? FORMTEXT ??? FORMTEXT ??? FORMTEXT ???A client-centered nursing care plan clearly noted (Pending or planned interventions and evaluation of outcomes). OAR 851-045-0060 (2) FORMTEXT ??? FORMTEXT ??? FORMTEXT ??? FORMTEXT ??? FORMTEXT ??? FORMTEXT ??? FORMTEXT ??? FORMTEXT ??? FORMTEXT ??? FORMTEXT ??? FORMTEXT ??? FORMTEXT ???Identifies measurable outcomes. FORMTEXT ??? FORMTEXT ??? FORMTEXT ??? FORMTEXT ??? FORMTEXT ??? FORMTEXT ??? FORMTEXT ??? FORMTEXT ??? FORMTEXT ??? FORMTEXT ??? FORMTEXT ??? FORMTEXT ???Nursing interventions documented. OAR 851-045-0060 (2) FORMTEXT ??? FORMTEXT ??? FORMTEXT ??? FORMTEXT ??? FORMTEXT ??? FORMTEXT ??? FORMTEXT ??? FORMTEXT ??? FORMTEXT ??? FORMTEXT ??? FORMTEXT ??? FORMTEXT ???Priority interventions clearly linked to assessment and nursing diagnosis. FORMTEXT ??? FORMTEXT ??? FORMTEXT ??? FORMTEXT ??? FORMTEXT ??? FORMTEXT ??? FORMTEXT ??? FORMTEXT ??? FORMTEXT ??? FORMTEXT ??? FORMTEXT ??? FORMTEXT ???Interventions include activities completed during current visit and activities planned for future visits. FORMTEXT ??? FORMTEXT ??? FORMTEXT ??? FORMTEXT ??? FORMTEXT ??? FORMTEXT ??? FORMTEXT ??? FORMTEXT ??? FORMTEXT ??? FORMTEXT ??? FORMTEXT ??? FORMTEXT ???Client Outcomes documented. OAR 851-045-0060 (2) FORMTEXT ??? FORMTEXT ??? FORMTEXT ??? FORMTEXT ??? FORMTEXT ??? FORMTEXT ??? FORMTEXT ??? FORMTEXT ??? FORMTEXT ??? FORMTEXT ??? FORMTEXT ??? FORMTEXT ???Client response to interventions and progress toward outcomes are noted and used to reassess and revise plan of care (evaluation). OAR 851-045-0060 (2) FORMTEXT ??? FORMTEXT ??? FORMTEXT ??? FORMTEXT ??? FORMTEXT ??? FORMTEXT ??? FORMTEXT ??? FORMTEXT ??? FORMTEXT ??? FORMTEXT ??? FORMTEXT ??? FORMTEXT ???NFP Home Visit Form includes feedback about previous activities and plan for next visit with “nurse agrees, and client agrees” content. NFP Contract Model Element 10 (See useful forms for supervisors) FORMTEXT ??? FORMTEXT ??? FORMTEXT ??? FORMTEXT ??? FORMTEXT ??? FORMTEXT ??? FORMTEXT ??? FORMTEXT ??? FORMTEXT ??? FORMTEXT ??? FORMTEXT ??? FORMTEXT ???Targeted Case Management (TCM)TCM visit is clearly documented. OAR 410-138-0060 (11) (c) FORMTEXT ??? FORMTEXT ??? FORMTEXT ??? FORMTEXT ??? FORMTEXT ??? FORMTEXT ??? FORMTEXT ??? FORMTEXT ??? FORMTEXT ??? FORMTEXT ??? FORMTEXT ??? FORMTEXT ???TCM Assessment and plan document is completed appropriately at initiation of TCM services. For agencies using an EMR, all components of the TCM Assessment and Plan form are captured and retrievable. OAR 410-138-0060 (11) (c) FORMTEXT ??? FORMTEXT ??? FORMTEXT ??? FORMTEXT ??? FORMTEXT ??? FORMTEXT ??? FORMTEXT ??? FORMTEXT ??? FORMTEXT ??? FORMTEXT ??? FORMTEXT ??? FORMTEXT ???TCM Assessment FORMTEXT ??? FORMTEXT ??? FORMTEXT ??? FORMTEXT ??? FORMTEXT ??? FORMTEXT ??? FORMTEXT ??? FORMTEXT ??? FORMTEXT ??? FORMTEXT ??? FORMTEXT ??? FORMTEXT ???TCM Service Plan with Goal(s). FORMTEXT ??? FORMTEXT ??? FORMTEXT ??? FORMTEXT ??? FORMTEXT ??? FORMTEXT ??? FORMTEXT ??? FORMTEXT ??? FORMTEXT ??? FORMTEXT ??? FORMTEXT ??? FORMTEXT ???TCM Plan is reviewed at each TCM visit and revised, as necessary. At a minimum, TCM Plan is revised annually. OAR 410-138-0060 (11) (c) FORMTEXT ??? FORMTEXT ??? FORMTEXT ??? FORMTEXT ??? FORMTEXT ??? FORMTEXT ??? FORMTEXT ??? FORMTEXT ??? FORMTEXT ??? FORMTEXT ??? FORMTEXT ??? FORMTEXT ???TCM Visit form is completed for each TCM visit, documenting TCM activities. For agencies using an EMR, all components of the TCM Visit form are captured and retrievable. OAR 410-138-0060 (11) (c) FORMTEXT ??? FORMTEXT ??? FORMTEXT ??? FORMTEXT ??? FORMTEXT ??? FORMTEXT ??? FORMTEXT ??? FORMTEXT ??? FORMTEXT ??? FORMTEXT ??? FORMTEXT ??? FORMTEXT ???General charting expectations: Document exceptions observed, include health record numberChart is clear and easy to read. Charts are assembled in a consistent manner across the program/team members. FORMTEXT ???Entries are completed in a timely manner, policy is in place for timeliness and includes an exception process as well as a delayed entry instruction. (PE 42(6)(d)) FORMTEXT ???Each entry is dated with the type of visit (e.g., HV, TC) FORMTEXT ???Entries in chronological order FORMTEXT ???Each entry dated and signed with title FORMTEXT ???Each page/screen identified with client name and birthdate FORMTEXT ???Entries legible FORMTEXT ???All entries typed or in ink. FORMTEXT ???Errors marked through with one line and initialed, EMR tracks late entries and error corrections. FORMTEXT ???If spaces are left open, they are marked through and initialed or signed. FORMTEXT ???Use of approved abbreviations only (yearly update). FORMTEXT ???An up-to-date record of initials, names and titles kept on file. FORMTEXT ???If records leave the building, a written policy is in place that specifies the agency’s practice regarding secure transportation of medical records. FORMTEXT ???Medical records in facility are secured. Measures are in place to maintain security of medical records. HIPPA Privacy Rules FORMTEXT ???Notes: FORMTEXT ????? ................
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