Maternal and Infant Chart Review Tool - SOM - State of … · 2016-11-17 · Maternal and Infant Chart Review Tool Reviewer Initials: ... Closed maternal charts with high maternal

Maternal and Infant Chart Review Tool Reviewer Initials: Agency: Date: Case Status: Open Closed

Client Initial: Birth date: Medicaid Number: EDC/Gestation: Referral Date: 1st Contact Date: Risk Identifier – Date/Discipline/Location

Program Chart Review Tool 8/1/2016; rev 11-7-16

_________ ___________ _________________ _______________ ____________ ______________ __________ _________ ________

#1 – Chart Forms (All Charts) Yes No NA

Correctly Dated Forms in Chart

Electronic health record

contains same data elements,

in same order as MDHHS forms

Appropriately altered data

entries

If no, what was missing:

Comments:

#2 – Professional Visit

Progress Notes (All

Charts)

# PVPN

Accurate

#PVPN

Reviewed

Professional Visit Progress

Notes

# of PVPN complete

and accurate

# of PVPN legible

# of PVPN reflecting

POC 1 and/or POC 2

If no, what was missing:

Comments:

#7 – Required Disciplines

(Closed Charts)

N/A

YES NO

At least 1 RN and 1 SW visit during

course of service or documentation of

beneficiary refusal (Only charts with RI

after 7/31/16)

Comments:

#3 – Consent to

Participate & to Release

Protected Health

Information (All Charts)

Participate PHI

Y N N

A

Y N N

A

Correct Agency Name

Consent to participate

in risk identifier checked

Consent to participate

in MIHP checked

Name of health care

provider, date signed,

and Initialed by

beneficiary

Name of other parties

PHI may be shared,

date signed, and

initialed by beneficiary

Consent to release PHI

box checked

Beneficiary/legal

representative name

printed

Signature of Beneficiary/

legal representative

If legal representative,

relationship to

beneficiary

Signed and dated

before risk identifier

administered

Signature of MIHP

interviewer

Date signed by

interviewer

Comments:

# 5 - Timely Entry of Discharge

(All Charts)

Yes No

Discharged within 30 days of:

End of pregnant woman’s

MIHP eligibility period.

Conclusion of infant services

or four consecutive months of

inactivity for infant unless

documentation on contact

log of why case is kept open.

Comments:

#6 OB-Based Maternal

Only Programs

(grandfathered in)

N/A

Yes No

1st maternal home visit within 1

month of enrollment or document

home visit refusal.

2nd maternal home visit done post-

partum, or document home visit

refusal

Infant referral made within 1 month

of maternal enrollment in MIHP.

Beneficiary transitioned to the

infant services provider, as

documented in the chart.

Documentation infant enrollment

status (infant receiving services,

refused, or unable to locate)

Comments:

Maternal and Infant Chart Review Tool Client Initials:

2 Program Chart Review Tool 8/1/16; rev. 11-17-16

#9 – RD Order (All Charts) N/A

YES NO

Visits by RD include order for RD services signed & dated by

health care provider or Medicaid health plan.

Charts that include a standing RD order show the order

signed & dated by a health care provider or Medicaid

health plan in last 12 months.

#10 – Nutrition Services (All Charts) N/A

YES NO

Closed maternal charts with high maternal nutrition risk

document nutrition counseling by RD or documentation

referral was offered/made.

Closed infant charts with high infant feeding and nutrition risk

document nutrition counseling by RD or documentation

referral was offered/made.

Open or closed charts in which an RD provided nutrition

counseling, clearly identify the entity that provided nutrition

counseling on a PVPN.

#21 – Referral to the MIHP (All Charts) YES NO NA

Pregnant beneficiary contacted within 14 calendar

days after referral.

Family was contacted within 7 calendar days after

referral for the infant.

Family was contacted within 48 hours of hospital

discharge for infant referrals received prior to infant’s

discharge from the inpatient setting.

Comments:

#22 – Medical Care Provider Notification (All Charts) YES NO

Provider notified within 14 calendar days of beneficiary

enrollment in MIHP, unless MIHP is part of OB/pediatric

practice & documentation is on file.

Notification of MIHP Enrollment Form A Cover Letter (M020

or I009) is in the chart.

Prenatal/Infant Communication (M022/I010) form is

complete & accurate in each required data field

Date Notified: Comments:

#23 – Medical Care Provider Notification with

significant changes (All Charts)

N/A

YES NO

Provider notified when significant change documented,

unless MIHP is part of OB/pediatric practice &

documentation is on file.

When a significant change documented, the Notification

of Change in Risk Factors Form B Cover Letter (M023 or

I012) is in the chart.

When significant changes documented the

Prenatal/Infant Communication (M022/I010) form is

complete and accurate in each required data field

Comments:

# 24 Risk identifier (RI) (M500 or I500) and

Consultant Authorization of Services. (All Charts)

YES NO NA

Risk Identifier Completed

Scoring Results Page

RI done before plan of care developed & before

additional services done unless documentation

of emergency visit.

If no risk listed on RI, chart has written

authorization from the MIHP consultant and

documentation supporting the benefit of further

MIHP services to beneficiary.

If infant is over the age of 12.0 months and not

enrolled in MIHP, chart has written authorization

from the MIHP consultant to enroll the infant and

documentation supporting the benefit of MIHP

services to this beneficiary.

Discipline completing identifier RN SW

Location of Visit Home Office Other

Comments:



#26 – Developmental Screening - ALL INFANT CHARTS

Note: The New ASQ SE-2 Summary Sheet was required as of 8/1/16

ASQ 3 and

ASQ SE-2: Check

screener

done

Date of

Screener

Correct

Screener

Score

W=White

G=Gray

B=Black

Appropriate

follow-up

Yes/No

Early-on

&/or IMH

Referral

made prn

Yes No W G B Yes No Y

e

s

N

o

N

A

⃝ ASQ 3 ⃝ ASQ SE-2





⃝ ASQ 3

⃝ ASQ SE-2

⃝ ASQ 3

⃝ ASQ SE-2

⃝ ASQ 3

⃝ ASQ SE-2

⃝ ASQ 3

⃝ ASQ SE-2

⃝ ASQ 3

⃝ ASQ SE-2

⃝ ASQ 3

⃝ ASQ SE-2

N/A – Maternal Chart

#26 – Developmental Screening – Infant Charts

Conducting and Documenting Developmental Screenings #26, Part 2

Yes No NA

Bright Futures results requiring follow-up screening,

indicate that follow-up screening was conducted

within two weeks.

ASQ-3 and ASQ: SE-2 Information Summary sheets.

ASQ-3 and ASQ: SE-2 Information Summary sheets

are complete and accurate

Appropriate ASQ-3 and ASQ: SE-2 questionnaires

used, corrected for prematurity, if applicable.

ASQ-3s screening repeatedly conducted at time

intervals specified in the Operation Guide

Learning activities were shared with family when

ASQ-3 /ASQ: SE-2 scored close to cutoff (in the

gray area) in one or more domains.

Comments:

#26 – Developmental Screening – Infant Charts

Developmental Screening Follow up #26, Part 3 Yes No N/A

If score was below ASQ-3 or above ASQ:SE-2 cut

off, a referral to Early-On was made or discussed

with family

If referral to Early On was indicated but family

declined referral or child didn’t qualify, learning

activities were shared with the family.

ASQ-3 or ASQ:SE-2 scoring close to the cutoff (in

the gray area) document that infant was

screened again or there were plans to screen

again in two months.

Comments:



MATERNAL CHART

FORM

Indicators: #24,

#27b, #32, #33, #56

Risk

Score

# 27B

POC2

pulled

matches

risk

#27

Added Risk,

or risk

match POC2

criteria

column 2

w/date in

column 1

# 32

Visit # High

risk

addressed

or

document

why not

#32

Closed

charts

address

Safety Plan

or

document

why not

#33

Closed

charts

address All

risk domains

in POC 2 or

document

why not

#33

Closed charts

List intervention

numbers addressed

on Risk Identifier and

progress notes

#27E

Closed charts

List intervention

numbers that show

date addressed on

POC2

#56 B

Closed charts

List intervention

numbers addressed

on D/C Summary

Domain L, M,

H, Unk L, M, H, N/A

N/A

N/A

N/A

N/A

N/A

N/A

Health History

Pregnancy

Health History

Asthma

Health History

Diabetes

Health History

Hypertension

Family Planning

Nutrition

Smoking

Alcohol

Drug Use

Stress/Depression

Social Support

Abuse/Violence

Basic Needs

Housing

Basic Needs

Transportation

Basic Needs Food

Breast Feeding



INFANT CHART

FORM

Indicators: #24,

#27b, #32, #33, #56

Risk

Score

# 27B

POC2

pulled

matches

risk

#27

Added Risk,

or risk

match POC2

criteria

column 2

w/date in

column 1

# 32

Visit # High

risk

addressed

or

document

why not

#32

Closed

charts

address

Safety Plan

or

document

why not

#33

Closed

charts

address All

risk domains

in POC 2 or

document

why not

#33

Closed charts

List intervention

numbers addressed

on Risk Identifier and

progress notes

#27E

Closed charts

List intervention

numbers that show

date addressed on

POC2

#56 B

Closed charts

List intervention

numbers addressed

on D/C Summary

Domain L, M, H,

Unk L, M, H, N/A

N/A

N/A

N/A

N/A

N/A

N/A

Infant

Family and Social

Support

Infant Health Care

Infant Safety

Infant Feeding and

Nutrition

Infant

Development

Maternal

Considerations

Family Planning

Smoking

Alcohol

Drug Use

Stress/Depression

Abuse/Violence

Basic Needs

Housing

Basic Needs Food

Breast Feeding



#27, Part 1 – POC 1 and Indicator #28 YES NO

Complete and accurate POC1:

Beneficiary received Maternal and Infant Education Packet

or staff assisted beneficiary to sign up for text4baby, or both.

Signatures of registered nurse and licensed social worker.

Signatures of RN and LSW dated within 10 business days of

each other.

Care coordinator is identified and documented

Comments:

#27, Part 3 – POC 3 and Indicator #28 YES NO N/A

Complete and accurate POC3:

Corresponds to the POC2 (if added risk domain)

Signatures of RN and LSW dated within 10 business days

of each other agreeing to the POC2

Signed and dated before any MIHP services are

provided, except in an emergency situation, which is

clearly documented

When additional risk domain is added to the POC 2

after the original POC 3 is signed, the POC 3 is updated

Care coordinator is identified and documented

A change in care coordinator during the course of

care, is documented

Comments:

#29 – Care Coordination (All Charts) Yes No N/A

Closed charts have Maternal or Infant Forms Checklist

(M001 or I001) that are complete and accurate.

Contact Log used to document attempts to contact

beneficiary and to coordinate care.

Visits are conducted at least monthly unless there is

documentation as to why this wasn’t done (effective

8/1/16).

Comments:

#30 – Referrals (All Charts) Yes No N/A

Referrals being made and documented as required in

MIHP operation guide

Staff follows up on at least 80% of referrals made within

3 professional visits from the date of referral

Referral outcomes documented on PVPN under

“outcome of previous referrals” & include which

referral is being addressed & status of the referral.

Beneficiary scoring M or H on stress/depression domain,

had mental health referral (and/or infant mental

health referral) or documentation as to why referral

was not made (Charts opened after 7/31/16)

Comments:

#35 – Additional Infant Services (Infant Charts) Yes No N/A

Infant chart with additional 9 visits has had no more visits

conducted or billed before date of written order.

Infant chart with additional 9 visits has reasons for extra

visits documented on physician order or PVPN.

If standing order authorizing additional visits on file, order

reviewed & signed by physician within the last 12 months.

Infant over 18.0 months has written authorization from

MIHP consultant and documentation supporting benefit

of continuation of services.

Comments:



#37 – Infant Services – Multiple Births (Infant Charts) N/A

YES NO

Infant chart indicating multiple births:

Documents the IRI has been completed for each infant and

billed to the infant’s Medicaid ID

Documents separate IRIs, POCs, ASQ-3s, ASQ: SE-2s, and

Discharge Summaries (closed only) are on file for each infant.

Documents that PVPNs for blended visits are on file in a family

chart; infant chart whose Medicaid ID being billed; or in a

separate chart for each family member.

Documents Notification of Multiple Charts Open (099) on file in

each infant’s chart when blended visits are being provided,

unless a family chart is used.

Documents professional visits are blended and consistently

billed under only one infant’s Medicaid ID.

#41 – Community Visits (All Charts) N/A

YES NO

Charts indicating community visits document reason why the

beneficiary could not be seen in home or office on the PVPN

(MIHP 011) for each community visit.

Comments:

#42 – Home Visits (All Maternal Charts) Yes No NA

Maternal charts document at least one prenatal home visit

or, in clinic-based program, coordination with appropriate

MIHP infant services provider, or document beneficiary

declined the prenatal home visit

Closed maternal charts document one post-partum home

visit was made or, in an OB clinic-based program that the

hand-off was made to the appropriate MIHP infant services

provider (excludes MOMS clients).

Maternal charts that document maternal postpartum visit

and Infant Risk Identifier visit made on the same day,

indicate the reason why both visits were on same day

Comments:

#45 – CBE (Closed Maternal Charts) N/A

Yes No

Closed maternal charts which document that beneficiary is a

first-time mother, indicate on a PVPN that beneficiary was

encouraged to attend CBE classes

#46 – CBE in Home (Maternal charts indicating

beneficiary received in-home CBE) N/A

Yes Yes

Include written documentation from medical care provider

stating why in-home CBE is needed.

Document at least ½ of the curriculum was covered.

#47 – CBE (Maternal charts indicating CBE classes

are provided) N/A

Yes NA

Document the pregnant woman attends at least ½ of classes

or covers at least ½ of curriculum described in class

schedule, before Medicaid is billed.

Document that CBE is billed one time per beneficiary per

pregnancy.

#48 – Parenting Ed (Infant charts indicating

parenting education is provided) N/A

Yes No

Document beneficiary’s caregiver attends at least ½ of the

parenting education classes or covers ½ of curriculum

described in class schedule, before Medicaid is billed.

Document it is billed one time per infant or per family in the

case of multiple births.

#50 – CPS (All Charts) N/A

Yes No

Charts which document possible child abuse or neglect,

indicate on a PVPN that immediate referrals are made to

CPS.



#51 – Family Planning (All Charts-PVPN after 7/31/16) Yes No NA

Maternal charts indicate family planning is discussed at

every maternal visit with referrals to family planning services

as needed, as documented on the PVPN.

Infant charts indicate family planning is discussed with

mother or father (if he is primary caregiver) at every infant

visit unless mother has undergone operative or non-

operative permanent sterilization, or the mother/father

refuses.

Comments:

#52 – Immunizations (All Charts-Infant PVPN after 7/31/16) Yes No NA

Closed maternal charts indicate mother’s immunization

status was discussed & documented on PVPN at least once.

Closed maternal charts indicate infant immunizations were

discussed & documented on PVPN at least once.

Infant charts indicate infant’s immunization status was

discussed at every visit, as documented on every PVPN.

Comments:

#54 – Transportation (All Charts) Yes No NA

Charts which include transportation domain in POC 2,

indicate transportation was provided and identify the

provider in a PVPN.

Comments:

#56 – Discharge (D/C) Summary (All Closed Charts N/A

Yes No

Closed charts include a Maternal or Infant Discharge Summary

(M200/I200) that is complete and accurate.

Closed charts document D/C Summary sent to medical care

provider within 14 days of entering the D/C Summary in MDHHS

database, unless MIHP is part of OB or pediatric practice & MIHP

has signed statement indicating that notification is not necessary.

Comments:

#57 – Transfers (All Charts) N/A

Yes No

Charts indicating beneficiary transfer to another MIHP provider:

Include a complete and accurate Consent to Transfer MIHP

Record to a Different Provider (Consent to Release Protected

Health Information) (M402), signed by beneficiary &

maintained on file after beneficiary information is sent to the

new provider.

Indicate that services were not billed after the transfer request

was received.

Indicate that the receiving provider obtained the beneficiary’s

information from the transferring provider before providing

services to the beneficiary, except in an emergency situation

which is documented in the chart.

Comments:

#59 – Lactation Support Services

(Charts that have billed for lactation support)

N/A

Yes No

Charts indicating lactation support services were conducted

and billed separately from the other nine maternal visits, show

HCPCS code S9443 was used on paid claim, and claim billed to

mother’s Medicaid ID

Charts indicating lactation support services were conducted

using code S9443 document:

The IBCLC PVPN was used and was complete and accurate.

Services were rendered by an IBCLC credentialed MIHP RN or

LSW and IBCLC certification is valid and current.

A need for maternal lactation support.

The initial assessment visit, appropriate RI (infant or maternal)

and POC (infant or maternal) is completed and the Risk

Identifier is entered into the MIHP database.

That comprehensive lactation counseling services were

provided according to the MSA15-46 policy.

Comments:



PVPN #1 First Time Mom

Date of Visit: Discipline Making Visit:

PVPN Top of progress note complete and accurate. Yes: No:

If not, document missing items:

List Domain Risk #1: Risk Level:

List Intervention Numbers:

Mom/caregiver Intervention Reaction: Yes No

High Risk in first 3 visits: Yes No N/A

Safety Plan: Yes No N/A
















PVPN page 2 complete and accurate. Yes: No:

Maternal Immunization Yes No Infant Immunization Yes No

Family planning Yes No Plan for next visit Yes No Signature of professional Yes No

List Referral(s) documented: Outcome of previous referral Documented Yes No N/A

PVPN #2

























Maternal Immunization Yes No Infant Immunization Yes No

Family planning Yes No Plan for next visit Yes No Signature of professional Yes No




PVPN #3

























Maternal Immunization Yes No Infant Immunization Yes No Family planning Yes No Plan for next visit Yes No Signature of professional Yes No


PVPN #4





























Requirements: First Time Mom Offered CBE (Closed Charts): Yes No N/A

Mental Health/Infant Mental Health Referral made for beneficiaries with Moderate or High Risk Depression or Documentation why not: Yes No N/A

Comments and Notes:

PVPN #5

























