II. Clinical Record : The shall contain, but is not limited to : participants’ clinical record General Case management Activities Code: Policy/Procedure 630.220d Manual Documentation of: Cornerstone Chart Review Missed appointments and attempts to Manual All Kids Log follow-up on missed appointments of (optional) those participants the case manager or physician have identified as Cornerstone Report and Each service rendered by the case Screens: PA07 Enrollment manager (PA03) Home visits: AR Infant Program Info Face-to-face: AR infants (PA15) Face-to-face: AR prenatal Most recent NAR Pregnant & Infant Cornerstone Well Child Visit Quarterly Perf. Reports, Release Immunizations current for age or of Information Consent, SV01 Perinatal depression screening Service, AS01 Family Planning Status Entry/comment FP: PA10 Release of information to providers of Postpartum necessary services SV02 Activity, Coordination of Care PA14 NOTE: If client has received Perinatal Depression Screening by Adequacy of Prenatal Care (Kessner Entry for PCP, document on SV01 screen listing provider with date Index) contacts-Work screened or if using the optional AS01 CMSE screen list provider with the date screened. The CMSE responses will populate the First trimester initiation of prenatal Plan defined, SV01, but the comments will not transfer. RF03 Referral care History Primary Physician Notified of FCM NOTE: Medical care coordination includes adequacy of prenatal care, all referrals needed are made, including follow up, Contract enrollment immunizations, EPSDT visits & PCP. Case notes coordination EI referral/all referrals with medical provider.
II. Clinical Record : The participants’ clinical record shall contain, but is not limited to : General Case management Activities Documentation of: Missed appointments and attempts to follow-up on missed appointments of those participants the case manager or physician have identified as Code: 630.220d Cornerstone Manual Policy/Procedure Manual Chart Review All Kids Log (optional) Cornerstone Report and Screens: PA07 Enrollment (PA03) Program Info (PA15) Most recent Cornerstone Quarterly Perf. Reports, Release of Information Consent, SV01 Service, AS01 Entry/comment FP: PA10 Postpartum SV02 Activity, PA14 Entry for contacts-Work Plan defined, RF03 Referral History Contract Each service rendered by the case manager Home visits: AR Infant Face-to-face: AR infants Face-to-face: AR prenatal NAR Pregnant & Infant Well Child Visit Immunizations current for age or Perinatal depression screening Family Planning Status Release of information to providers of necessary services Coordination of Care Adequacy of Prenatal Care (Kessner Index) First trimester initiation of prenatal care Primary Physician Notified of FCM enrollment EI referral/all referrals NOTE: If client has received Perinatal Depression Screening by PCP, document on SV01 screen listing provider with date screened or if using the optional AS01 CMSE screen list provider with the date screened. The CMSE responses will populate the SV01, but the comments will not transfer. NOTE: Medical care coordination includes adequacy of prenatal care, all referrals needed are made, including follow up, immunizations, EPSDT visits & PCP. Case notes coordination with medical provider.