Bureau of Maternal and Infant Health, Illinois Department of Human Services FY18 BBO Chart Review Tool: Terminated Clients Agency: Present = X Review Date: Absent = 0 Not Applicable = NA MCH Nurse Consultant: Cornerstone ID Number X 0 NA Participant Assigned Case Manager Profile: PA02 BBO Initiation Date Program Client transitioned to the most Information: appropriate services at 6 weeks PA15 (or RF01) postpartum (FCM or HV Program) EDC date Initial Prenatal: Month Care Began PA07 (or SV01:802) Trimester Care Began Postpartum: PA10 # of prenatal medical visits (SV01:802) 707G: Risk Factors - HSPR0207 Assessment: Assessment Report (list): AS01 706 Home: at initial HV F2F visit documented for each Activity Entry: period of client enrollment up to SV02-100 or termination from BBO. 105 F2F visits completed by assigned Contact Type 1 BBO case manager. or 2 or 3 Other contact documented for each (Activity dates 31-day period of client enrollment are on or after Site:01: Home visit documented for IPCM Effective each trimester of pregnancy during From Date) enrollment period client’s CM02 - Goals CM03 - Planned Services CM02 or CM03: Updates on Care Care Plan Plan with Dates CM02, CM03, CM04: Content of each face-to-face CM04 interaction is documented CM04: Content of each other contact interaction is documented CM04: Content of each home visit interaction is documented
Bureau of Maternal and Infant Health, Illinois Department of Human Services FY18 BBO Chart Review Tool: Terminated Clients Agency: Present = X Absent = 0 Not Applicable = NA Review Date: MCH Nurse Consultant: Cornerstone ID Number X 0 NA Participant Profile: PA02 Assigned Case Manager Program Information: PA15 (or RF01) BBO Initiation Date Client transitioned to the most appropriate services at 6 weeks postpartum (FCM or HV Program) Initial Prenatal: PA07 (or SV01:802) EDC date Month Care Began Trimester Care Began Postpartum: PA10 (SV01:802) # of prenatal medical visits Assessment: AS01 707G: Risk Factors - HSPR0207 Assessment Report (list): 706 Home: at initial HV Activity Entry: SV02-100 or 105 Contact Type 1 or 2 or 3 (Activity dates are on or after IPCM Effective From Date) F2F visit documented for each period of client enrollment up to termination from BBO. F2F visits completed by assigned BBO case manager. Other contact documented for each 31-day period of client enrollment Site:01: Home visit documented for each trimester of pregnancy during client’s enrollment period Care Plan CM02, CM03, CM04 CM02 - Goals CM03 - Planned Services CM02 or CM03: Updates on Care Plan with Dates CM04: Content of each face-to-face interaction is documented CM04: Content of each other contact interaction is documented CM04: Content of each home visit interaction is documented
FY18BBOChartReviewToolTerminated.docx