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DC HealthCheck's Standard Medical Record Forms (SMRFs)

DC HealthCheck's Standard Medical Record Forms (SMRFs). Outline. Purpose Authority, Credibility, and Peer Review Implementation Data Collection and Confidentiality Summary: How the SMRFs can benefit providers. Purpose.

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DC HealthCheck's Standard Medical Record Forms (SMRFs)

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  1. DC HealthCheck's Standard Medical Record Forms (SMRFs)

  2. Outline • Purpose • Authority, Credibility, and Peer Review • Implementation • Data Collection and Confidentiality • Summary: How the SMRFs can benefit providers

  3. Purpose • Ensure that the District's youth receive all required health care services • Advance the standards of care set forth by HealthCheck [DC's Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) program] and federal EPSDT regulations • Help providers streamline documentation and maximize reimbursements • Improve and standardize data collection, and establish linkages with the DC Immunization Registry • Provide a mechanism to support mandated review activities and quality improvement initiatives

  4. Authority, Credibility, and Peer Review The SMRFs are in compliance with federal regulations 42 U.S.C. 1396d(r) and are based on the standards of care outlined in: • The HealthCheck Periodicity Schedule, in consultation with the local medical community • The American Academy of Pediatrics (AAP) Recommendations for Preventive Pediatric Health Care • The Centers for Medicare & Medicaid Services (CMS) Medicaid Manual • The Bright Futures Guidelines for Health Supervision of Infants, Children, and Adolescents

  5. Implementation ONLY 7 forms covering the content of well-child visits for children ages 0 to 21 years

  6. Implementation continued… Front of each form documents all components of a well-child visit: • child/family concerns and history • review of systems • unclothed physical examination • immunizations, screenings, guidance

  7. Implementation continued… The reverse side lists: • age-appropriate developmental milestones • Bright Futures anticipatory guidance • any specific concerns NOTE: Only the front side of the form will be used for EPSDT documentation.

  8. Data Collection and Confidentiality • Use same system successfully in place through the DC Immunization Registry (DCIR) for the Vaccines For Children program • Batch and send carbon copy of front side to DCIR • EPSDT data (front side only) entered into the registry by data entry personnel • Scanned copy will be accessible to providers authorized to review these records.

  9. Data Collection and Confidentiality • Registry and its contents are strictly confidential • DCIR uses the most advanced technology to protect this confidentiality following all HIPAA regulations, and will track and monitor usage closely • Any unauthorized or authorized party using the registry for inappropriate use will be prosecuted to the fullest extent of DC and federal law.

  10. Summary: How the SMRFs can benefit providers Developed by providers specifically for providers, this documentation tool can help providers effectively be even more effective in these ways: • Documentation required content of care for each well-child visit • Access for providers to their own patients' health records in a secure database • A pay-for-performance incentive for each completed SMRF

  11. DOCUMENTATION REQUIRED FOR COMPLIANCE WITH HEALTHCHECK

  12. FOR ALL FORMS: • The reverse side of the DC HealthCheck form can be used for additional information/comments, nursing notes, behavioral and developmental milestones, and anticipatory guidance. • The reverse side has age appropriate developmental milestones for reference. • The reverse side has age appropriate anticipatory guidance for reference based on Bright Futures (www.brightfutures.org/healthcheck.html). • Space is provided on the forms for additional notes.

  13. FOR ALL FORMS: • If the action was completed by the provider, the respective open box MUST be marked or it will not be considered completed. • At the top of every DC HealthCheck form: Please indicate whether a 1st or periodic visit, and fill in drug allergies. • At the top of every DC HealthCheck form: Please fill in demographic and insurance information, or use a sticker containing the required information. • At the top of everyDC HealthCheck form: Please fill in Name, Date/Time, Insurance ID number, Date of Birth, Gender, Weight, Height, and Head Circumference (up to 2 years of age).

  14. FOR ALL FORMS: • Vision Screen (required at 3,5,6,8,10,12,15,18 yrs old): must write in visual acuity and mark either corrected or uncorrected box or mark box next to unsuccessful attempt. • Hearing screen (required at 5,6,8,10,12,15,18 yrs old): must mark one of three boxes (passed, failed, or unsuccessful attempt). • History/Parent Concerns (2 month to 21 years): must check box next to interval history OR write in text on lines below. • Social/Family History: Should be reviewed with patient/guardian and checked when completed.

  15. FOR ALL FORMS: • Review of Systems: Should be reviewed with patient/guardian and completed. • For ages 0 to 5 years: The following boxes must be checked. • Nutrition Assessed • Elimination Assessed • Environment Assessed • Sleep Assessed • EITHER Development assessed (using Table on reverse) OR Denver Devel. II administered OR Other Tool administered.

  16. FOR ALL FORMS: • Anticipatory Guidance Provided: Should be reviewed with patient/guardian and “topics discussed and/or handout given” should be marked. • Physical Examination (Unclothed): Every item must be reviewed and marked NL (normal) or ABN (abnormal). Additional text may be written in space provided. • Assessment and Plan: • “Well Child” and/or “Additional Concerns,” Must Mark appropriate box. • "Education handouts and/or plan reviewed with patient/parent, who verbalizes understanding," Must Mark appropriate box.

  17. FOR ALL FORMS: • Immunizations/Screens: • Immunizations should be reviewed and appropriate box(es) MUST be marked. • TB Risk (12 months to 21 years): Assess risk, if ‘high’ then check “PPD Ordered.” NOTE: All children entering school must have a PPD test prior to entrance. • Cholesterol risk assessment (3 years to 21 years): Review risk factors. Must mark either “low” or “high.” Note: AAP recommends lipid profile at ages 6, 8, 10 annually if at high risk.

  18. FOR ALL FORMS: • Referrals: • If any referrals are made, mark the box “referrals made.” • Dental Referral (3 years to 21 years, required yearly), must complete and mark box. Refer a child at earlier ages if necessary. • Signature: Providers (Physicians, Nurse practitioners, Physicians Assistants, or resident/student trainee) must sign, print name and date.

  19. ADDITIONAL DOCUMENTATION REQUIREMENTS FOR SPECIFIC FORMS • 0-1 MONTH: • Birth/Parental Concerns: Review with guardian and mark completed. • Immunizations/Screens: • Newborn metabolic screen: must mark the appropriate box. If ABN write in the value. • Newborn hearing screen: must mark the appropriate box. • 2-4 MONTHS: • Immunizations/Screens: • Newborn metabolic screen: must mark the appropriate box. If ABN, write in thevalue. • Newborn hearing screen: must mark the appropriate box.

  20. REQUIREMENTS FOR SPECIFIC FORMS • 6-9 MONTHS: • Immunizations/Screens: • Anemia Screen (HGB/HCT): At 9 months must mark either "ordered” or "deferred until one year." • Lead Risk: Must assess and then mark appropriate box. If yes, mark ordered. • 12-18 MONTHS: • Immunizations/Screens: • Blood lead test: Required at 12 mos. or at later visit if not previously done. Also required if patient at high risk. Must mark one of three boxes for lead test (ordered, NL, or ABN). NOTE: if ABN, must write in result. • Anemia Screen (HGB/HCT): At 12 month visit must mark one of three boxes (ordered, NL, or ABN). NOTE: if ABN, must write in result.

  21. REQUIREMENTS FOR SPECIFIC FORMS • 2-5 YEARS: • Immunizations/Screens: • Blood lead test: Required at 24 mos. or at later visit if not previously done. Also required if patient at high risk. Must mark one of three boxes for lead test (ordered, NL, or ABN). NOTE: if ABN, must write in result. • 6-10 YEARS: • Immunizations/Screens: • Anemia Risk: Must mark “low” or “high” If “high” than check HGB/HCT ordered. NOTE: Recommended yearly for menstruating females.

  22. REQUIREMENTS FOR SPECIFIC FORMS • 11-21 YEARS: • Physical Examination (Unclothed): Pelvic exam is recommended for all sexually active females and yearly for those between ages 18 to 21 years. • Immunizations/Screens: • Anemia Risk: Must mark “low” or “high.” If “high,” then check HGB/HCT ordered. NOTE: Recommended yearly for menstruating females. • STD risk: must mark either “low” or “high” (if the box next to “high” is marked, must mark the box next to “screens ordered.”).

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