Form DHCS 4492 Medical Record Review Tool - California

Form DHCS4492 is a California Department of Health Care Services form also known as the "Medical Record Review Tool". The latest edition of the form was released in July 1, 2012 and is available for digital filing.

Download an up-to-date Form DHCS4492 in PDF-format down below or look it up on the California Department of Health Care Services Forms website.

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State of California Health and Human Services Agency
Department of Health Care Services
Child Health and Disability Prevention (CHDP) Program
MEDICAL RECORD REVIEW TOOL
CHDP Provider Name:
Office Contact Name(s):
Site Address:
Reviewer Name:
__________________________________________________________
Date:
Clinician
1)
3)
2)
4)
Criteria met: Give full points.
1
2
3
4
5
6
7
8
10
Score
Pass Fail
Criteria not met: 0 points.
9
Criteria not applicable: N/A (Give full points)
[ ] Electronic
Clinician
Wt.
[ ] Paper
Child ID
[ ] Hybrid
Age/Gender
1. Format Criteria
An individual medical record is established for each
A.
2
child/youth.
1)
Child/Youth identification is on each page.
2
Individual personal biographical information is
2)
1
documented.
3)
Emergency contact is identified.
1
4)
Each medical record is consistently organized.
1
Chart contents are securely fastened.
5)
1
Each medical record has documentation that the
parent/guardian of the child/youth has received a
6)
1
copy of the office's/clinic's notice of Privacy
Practices.
Comments:
Total Possible Per Chart
9
Section 1 Total Possible per Chart
Section 1 Total:
9
DHCS 4492 (07/12)
Page 1
State of California Health and Human Services Agency
Department of Health Care Services
Child Health and Disability Prevention (CHDP) Program
MEDICAL RECORD REVIEW TOOL
CHDP Provider Name:
Office Contact Name(s):
Site Address:
Reviewer Name:
__________________________________________________________
Date:
Clinician
1)
3)
2)
4)
Criteria met: Give full points.
1
2
3
4
5
6
7
8
10
Score
Pass Fail
Criteria not met: 0 points.
9
Criteria not applicable: N/A (Give full points)
[ ] Electronic
Clinician
Wt.
[ ] Paper
Child ID
[ ] Hybrid
Age/Gender
1. Format Criteria
An individual medical record is established for each
A.
2
child/youth.
1)
Child/Youth identification is on each page.
2
Individual personal biographical information is
2)
1
documented.
3)
Emergency contact is identified.
1
4)
Each medical record is consistently organized.
1
Chart contents are securely fastened.
5)
1
Each medical record has documentation that the
parent/guardian of the child/youth has received a
6)
1
copy of the office's/clinic's notice of Privacy
Practices.
Comments:
Total Possible Per Chart
9
Section 1 Total Possible per Chart
Section 1 Total:
9
DHCS 4492 (07/12)
Page 1
State of California Health and Human Services Agency
Department of Health Care Services
Criteria met: Give full points.
1
2
3
4
5
6
7
8
10
Score
Pass Fail
Criteria not met: 0 points.
9
Criteria not applicable: N/A (Give full points)
[ ] Electronic
Clinician
Wt.
[ ] Paper
Child ID
[ ] Hybrid
Age/Gender
2. Documentation Criteria
Allergies and adverse reactions are prominently noted
A.
2
at each well-child visit.
Health-related conditions are identified (e.g., problem
B.
1
list).
Current continuous medications are listed.
C.
1
D.
Appropriate consents are present:
1)
Consent for Treatment.
1
Release of Medical Information.
2)
1
3)
Informed Consent for specific procedure.
1
Errors are corrected according to legal medical
1
E.
documentation standards.
All entries are signed, co-signed if applicable, dated, and
2
F.
legible.
Copy of completed pre-enrollment application (DHCS
G.
2
4073) in chart, if using Gateway.
Comments:
Total Possible Per Chart
12
Section 2 Total Possible Per Chart
Section 2 Total:
12
DHCS 4492 (07/12)
Page 2
State of California Health and Human Services Agency
Department of Health Care Services
Criteria met: Give full points.
1
2
3
4
5
6
7
8
10
Score
Pass Fail
Criteria not met: 0 points.
9
Criteria not applicable: N/A (Give full points)
[ ] Electronic
Clinician
[ ] Paper
Child ID
Wt.
[ ] Hybrid
Age/Gender
3. Coordination and Continuity of Care
Criteria
Comprehensive Health History.
A.
1)
Past Medical History.
3
2)
Social History.
2
3)
Review of systems.
2
4)
Family History.
2
□ Pass
Treatment plans address identified conditions
B.
2
□ Fail
found during history and physical examination.
□ Pass
Instructions of child/youth and/or primary caregiver
C.
2
□ Fail
for follow-up care are documented.
Unresolved and/or continuing problems are addressed
D.
2
and documented at the time of the subsequent visit.
□ Pass
Comments:
Total Possible Per Chart
15
□ Fail
Section Sub-Total:
DHCS 4492 (07/12)
Page 3
State of California Health and Human Services Agency
Department of Health Care Services
Criteria met: Give full points.
1
2
3
4
5
6
7
8
10
Score
Pass Fail
Criteria not met: 0 points.
9
Criteria not applicable: N/A (Give full points)
[ ] Electronic
Clinician
[ ] Paper
Child ID
Wt.
[ ] Hybrid
Age/Gender
3. Coordination and Continuity of Care
(Cont'd)
E.
Test results, reports, and referrals
Consultation, test results, diagnostic reports,
□ Pass
and referrals have explicit notation of review in
2
1)
□ Fail
the medical record.
Test results, diagnostic reports, referrals, and
□ Pass
consultation reports are discussed with
2)
2
□ Fail
parent(s), legal guardian, and/or child/youth with
explicit notation in the medical record.
If Health Assessment Only Provider, referred
3)
child/youth to a medical and dental home.
3
Or
If Comprehensive Health Provider, referred
child/youth to a dental home.
4)
Age appropriate referral to WIC.
2
Missed appointments and follow-up contacts/outreach
F.
2
efforts are documented.
□ Pass
Comments:
Total Possible Per Chart
11
□ Fail
Section 3 Total Possible Per Chart
26
Section Sub-Total:
□ Pass
□ Fail
Section 3 Total:
DHCS 4492 (07/12)
Page 4
State of California Health and Human Services Agency
Department of Health Care Services
Criteria met: Give full points.
1
2
3
4
5
6
7
8
10
Score
Pass Fail
Criteria not met: 0 points.
9
Criteria not applicable: N/A (Give full points)
[ ] Electronic
Clinician
Wt.
[ ] Paper
Child ID
[ ] Hybrid
Age/Gender
4. Pediatric Preventive Criteria
Developmental Screening Completed.
Tool
A.
2
Used:_________________________
Behavioral Screening Completed.
B.
2
Tool Used:_________________________
□ Pass
Vision Screening (Snellen Test or equivalent)
C.
2
□ Fail
completed and documented.
□ Pass
D.
Hearing Screening completed and documented.
2
□ Fail
E.
Fluoride use appropriate for age and location.
2
CHDP lab work is present and documented.
F.
□ Pass
Hb/Hct.
2
1)
□ Fail
Other testing is completed as appropriate.
2)
2
Lead counseling, screening ordered, and results
3)
2
documented.
TB risk assessment and/or tuberculin skin test (Mantoux)
G.
2
is completed.
□ Pass
Comments:
Total Possible Per Chart
18
□ Fail
Section Sub-Total:
DHCS 4492 (07/12)
Page 5

Download Form DHCS 4492 Medical Record Review Tool - California

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