ANNUAL Agency Name: RECERTIFICATION MCH Nurse Consultant: Region: Visit Date: # Active Charts Randomly Selected Woman: Infant: Child: Total = for review: # Records % in IDHS Report Data from Performance Standard # Expected # Completed OUTCOME INDICATOR: Reviewed Compliance Period IDHS Reports or State Average Assessments (701, 706 AR infants, AS01s AS01s AS01s 711 or 712 or 713,708 A-R infants, 90% Records Records Records Nutrition) Individual Care Plan 90% All Referrals on RF01, CM02, CM03, 100% CM04 including follow-up Initiation of prenatal care with medical 75% provider in 1st trimester ( PA07) Reproductive Life Plan 95% (SV01:941& 942) Preconception /Interconception Ed (SV01: PEWW) EI Referral (0-3) # Indicated # Expected 100% NAR Pregnant or Infant: 2 F2F +1 80% other contact AR Pregnant: 3 F2F (1 per trimester) 80% AR Infant:3 F2F + 1 HV 80% AR Infant: Home Visit: 1 HV 75% Primary Care Provider 95% Immunizations 3-2-2 90% EPSDT Visits FCM Infants Age 1: > 3 80% Developmental Screenings 80% (1 Standardized screen by12 months) Prenatal depression screening 95% Postpartum depression screening 95% AR & NAR Over rides HSPR0749 <10%
Agency Name: ANNUAL RECERTIFICATION MCH Nurse Consultant: Region: Visit Date: # Active Charts Randomly Selected for review: Woman: Infant: Child: Total = OUTCOME INDICATOR: # Records Reviewed # Expected # Completed % in Compliance IDHS Report Period Data from IDHS Reports Performance Standard or State Average Assessments (701, 706 AR infants, 711 or 712 or 713,708 A-R infants, Nutrition) AS01s AS01s AS01s 90% Records Records Records Individual Care Plan 90% All Referrals on RF01, CM02, CM03, CM04 including follow-up 100% Initiation of prenatal care with medical provider in 1st trimester ( PA07) 75% Reproductive Life Plan (SV01:941& 942) 95% Preconception /Interconception Ed (SV01: PEWW) EI Referral (0-3) # Indicated # Expected 100% NAR Pregnant or Infant: 2 F2F +1 other contact 80% AR Pregnant: 3 F2F (1 per trimester) 80% AR Infant:3 F2F + 1 HV 80% AR Infant: Home Visit: 1 HV 75% Primary Care Provider 95% Immunizations 3-2-2 90% EPSDT Visits FCM Infants Age 1: > 3 80% Developmental Screenings (1 Standardized screen by12 months) 80% Prenatal depression screening 95% Postpartum depression screening 95% AR & NAR Over rides HSPR0749 <10%
FY17_FCM_Clinical_Review_Tool.docx