DC HealthCheck's Standard Medical Record Forms SMRFs

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DC HealthCheck's Standard Medical Record Forms
(SMRFs)
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Outline

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

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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

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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

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Implementation

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

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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

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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.

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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.

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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.

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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

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DOCUMENTATION REQUIRED FOR COMPLIANCE WITH
HEALTHCHECK
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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.

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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 every DC 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).

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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.

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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.

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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.

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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.

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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.

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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 the value.
• Newborn hearing screen must mark the
  appropriate box.

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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.

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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.

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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.).