Recommendation: Hemoglobin Observation / Universal Precautions When possible Overall Rating: complete five (5) observations per clinic. At minimum complete 5 observations per District. 5 Looking For: HEMOCUE Staff observed using universal precautions? Followed correct procedures for collecting Scoring is based on district summary: hematological data? All observations conducted according to standards Hemoglobin was 5 Points (S) collected when One (1) to two (2) observations with noted deficiencies required? 4 Points (SN) MASIMO PRONTO Three (3) to four (4) observations with noted deficiencies 3 Points (U) Followed correct Five (5) or more observations with noted deficiencies procedures for 0 Points (U) collecting measurement. If measurement was unable to be collected using non-invasive means; screening completed using Hemocue. Hemoglogin collected when required? Hemoglobin Observation / Universal Precautions: (S = Satisfactory, SN = Satisfactory Needs Improvement, U = Unsatisfactory and N/A = Not Applicable) Clinic Date District Average: Reviewer Rating: (S / SN / U / NA) Clinic Points Awarded: Comments: (Note additional observations under comments if the clinic was rated as unsatisfactory) N. Formula Tracking Log / State Ordered Formula Tracking Log: S SN U NA Possible Points MO-77 Points Awarded Formula Tracking Log Formula Tracking Log / State Ordered Formula 5 book is required for all Tracking Log: Overall Rating: clinics. Clinic scoring by the following criteria: Formula Tracking logged according to standards State Ordered Formula 5 Points (S) Tracking Log is required One (1) to two (2) criteria with noted deficiencies for all clinics that 4 Points (SN) received state ordered Three (3) to four (4) criteria with noted deficiencies 3 formula within the Points (U) required five (5) years Five (5) or more criteria with noted deficiencies 0 plus current
Recommendation: When possible complete five (5) observations per clinic. At minimum complete 5 observations per District. Looking For: HEMOCUE Staff observed using universal precautions? Followed correct procedures for collecting hematological data? Hemoglobin was collected when required? MASIMO PRONTO Followed correct procedures for collecting measurement. If measurement was unable to be collected using non-invasive means; screening completed using Hemocue. Hemoglogin collected when required? Hemoglobin Observation / Universal Precautions Overall Rating: 5 Scoring is based on district summary: All observations conducted according to standards 5 Points (S) One (1) to two (2) observations with noted deficiencies 4 Points (SN) Three (3) to four (4) observations with noted deficiencies 3 Points (U) Five (5) or more observations with noted deficiencies 0 Points (U) Hemoglobin Observation / Universal Precautions: (S = Satisfactory, SN = Satisfactory Needs Improvement, U = Unsatisfactory and N/A = Not Applicable) Clinic District Average: Date Reviewer Rating: (S / SN / U / NA) Clinic Points Awarded: Comments: (Note additional observations under comments if the clinic was rated as unsatisfactory) N. Formula Tracking Log / State Ordered Formula Tracking Log: MO-77 S SN U NA Possible Points Points Awarded Formula Tracking Log book is required for all clinics. State Ordered Formula Tracking Log is required for all clinics that received state ordered formula within the required five (5) years plus current Formula Tracking Log / State Ordered Formula Tracking Log: Overall Rating: 5 Clinic scoring by the following criteria: Formula Tracking logged according to standards 5 Points (S) One (1) to two (2) criteria with noted deficiencies 4 Points (SN) Three (3) to four (4) criteria with noted deficiencies 3 Points (U) Five (5) or more criteria with noted deficiencies 0
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