"Record Review Form - Clinical Directors Network"

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Study ID:
CLINICAL DIRECTORS NETWORK, INC.
NYU SCHOOL of MEDICINE
Counseling African Americans To Control Hypertension (CAATCH) Study
RECORD REVIEW FORM
Review Date: (mm/dd/yy)
/
/
Time Start1:
Reviewer Code #
CHC Site and Code#
Chart #
Date Consented
/
/
Patient Demographics:
1.
DOB: (mm/dd/yy)
/
/
2.
Gender: ____Male ____Female
3.
Residence: County_____________ State_____
Zip Code________
4.
Race (check one only):
_____American Indian / Alaskan Native
_____Asian
_____Black
_____Native Hawaiian / Other Pacific Islander
_____White
_____Mixed
_____Other (Specify): _______________________________
_____Unknown / Not noted
5.
Ethnicity:
____African American
____Belizean
____Chinese
____Cuban
____Dominican
____Haitian
____Jamaican
____Japanese
____Mexican-American
____Middle Eastern
____Puerto Rican
____Trinidadian
____Vietnamese
____Other Central or S. American
____Other West Indian / Non-Latino Caribbean
____Other (Specify):_____________________________________
____Unknown / Not Noted
6.
Hispanic Origin ____Yes ____No
____Not Noted
7.
Place of Birth:
____ USA
____ Outside of USA, Country ______________________
____ Not Noted
8.
Marital Status (check one):
____Single
____Married
____Separated
____Divorced
____Member of an unmarried couple
____Widowed
____Not Noted
Study ID
Site #
Reviewer ID
G:\CAATCH\Assessments\Chart Review
1
Study ID:
CLINICAL DIRECTORS NETWORK, INC.
NYU SCHOOL of MEDICINE
Counseling African Americans To Control Hypertension (CAATCH) Study
RECORD REVIEW FORM
Review Date: (mm/dd/yy)
/
/
Time Start1:
Reviewer Code #
CHC Site and Code#
Chart #
Date Consented
/
/
Patient Demographics:
1.
DOB: (mm/dd/yy)
/
/
2.
Gender: ____Male ____Female
3.
Residence: County_____________ State_____
Zip Code________
4.
Race (check one only):
_____American Indian / Alaskan Native
_____Asian
_____Black
_____Native Hawaiian / Other Pacific Islander
_____White
_____Mixed
_____Other (Specify): _______________________________
_____Unknown / Not noted
5.
Ethnicity:
____African American
____Belizean
____Chinese
____Cuban
____Dominican
____Haitian
____Jamaican
____Japanese
____Mexican-American
____Middle Eastern
____Puerto Rican
____Trinidadian
____Vietnamese
____Other Central or S. American
____Other West Indian / Non-Latino Caribbean
____Other (Specify):_____________________________________
____Unknown / Not Noted
6.
Hispanic Origin ____Yes ____No
____Not Noted
7.
Place of Birth:
____ USA
____ Outside of USA, Country ______________________
____ Not Noted
8.
Marital Status (check one):
____Single
____Married
____Separated
____Divorced
____Member of an unmarried couple
____Widowed
____Not Noted
Study ID
Site #
Reviewer ID
G:\CAATCH\Assessments\Chart Review
1
9. Current Insurance Status (Check all that apply)
____ Medicaid (Fee for service)
____ Medicaid Managed Care (check one):
____ABC
____Affinity
____Americhoice
____CarePlus
___ Center Care
____Community Choice
____Community Premier Plus
____Fidelis Care
____Health First
____Health Plus
____HIP
____MetroPlus
____Neighborhood Health Providers
____New York Presbyterian CHP
____Partners in Health
____United HC
____WellCare
____Managed Care Plan (Other ______________________________________________)
____ Medicare /Medicare Managed Care
____ Employer / Private Insurance
____ Other (Specify______________________________________________)
____ None
____ Insurance Not Noted
Visit History:
10.
Date of First Visit and/or Progress Note: (mm/dd/yy)
/
/
11.
Date of Most Recent Visit: (mm/dd/yy)
/
/
12.
Date of Most Recent Primary Care Visit: (mm/dd/yy)
/
/
13.
Visit Count in the past 12 months ________
(Visits with MD, PA, NP, CNM: Internal Medicine, Family Medicine, OB/GYN)
14.
Visit Count in the past 12 months / other specialty NOT Cardiologist, Endocrinologist: ___________
(Visits with MD, PA, NP: Surgery, Podiatry, Psychiatry, Psychology, Urology)
15.
Date of most recent Cardiology Visit ____/____/____
Date of most recent Endocrinology Visit ___/___/__
Study ID
Site #
Reviewer ID
G:\CAATCH\Assessments\Chart Review
2
Medical History / Co-morbidities:
16.
Diabetes
____Yes
_____No
______Not Noted
17.
Hypertension
____Yes
_____No
______Not Noted
18.
Heart Attack
____Yes
_____No
______Not Noted
Heart Failure – Hospitalization
19.
____Yes
_____No
______Not Noted
20.
Stroke
____Yes
_____No
______Not Noted
21.
Acute Cardiovascular Syndrome
____Yes
_____No
______Not Noted
22.
Kidney Failure
____Yes
_____No
______Not Noted
23.
Proteinuria
____Yes
_____No
______Not Noted
24.
Hyperlipidemia / Dyslipidemia
____Yes
_____No
______Not Noted
25.
Obesity
____Yes
_____No
______Not Noted
26.
Cholesterol/Lipid Disorder
____Yes
_____No
______Not Noted
27.
Impaired glucose tolerance /
Metabolic Syndrome
____Yes
_____No
______Not Noted
28.
Depression
____Yes
_____No
______Not Noted
29.
Cancer
____Yes
_____No
______Not Noted
30.
Smoker
____ Current Smoker
____Former Smoker _______ Never Smoked
____Not Noted ____/____/___ Date noted in chart
Most Recent Laboratory Tests: (Indicate dates of last test or circle NN for not noted)
Test Item
Date
Results
Test Item
Date
Results
Total Chol.
/
/
NN
FBS
/
/
NN
HDL
/
/
NN
RBS
/
/
NN
LDL
/
/
NN
Serum K+
/
/
NN
VLDL
/
/
NN
Serum Creat.
/
/
NN
Spot Protein /
Triglycerides
/
/
NN
Creatinine
/
/
NN
HbA1C
/
/
NN
24 hr. Microalb
/
/
NN
CRP
/
/
NN
EGFR
/
/
NN
Height
ft
in.
or
cm.
Weight
Lbs.
Last Laboratory Tests Prior to Study Enrollment: (Indicate dates of last test or circle NN for not noted)
Test Item
Date
Results
Test Item
Date
Results
Total Chol.
/
/
NN
FBS
/
/
NN
HDL
/
/
NN
RBS
/
/
NN
LDL
/
/
NN
Serum K+
/
/
NN
VLDL
/
/
NN
Serum Creat.
/
/
NN
Spot Protein /
Triglycerides
/
/
NN
Creatinine
/
/
NN
HbA1C
/
/
NN
24 hr. Microalb
/
/
NN
Height
ft
in
or
cm.
Weight
Lbs.
Study ID
Site #
Reviewer ID
G:\CAATCH\Assessments\Chart Review
3
Vital Signs: Collect all Blood Pressure from today to 6 months prior to consent date
st
nd
rd
Date
Taken By
1
2
3
Heart Rate Weight (lbs)
1
2
3
4
5
SBP / DBP
SBP / DBP
SBP / DBP
/
/
MD NP/PA RN MA RC
NN
/
/
/
bpm
/
/
MD NP/PA RN MA RC
NN
/
/
/
bpm
/
/
MD NP/PA RN MA RC
NN
/
/
/
bpm
/
/
MD NP/PA RN MA RC
NN
/
/
/
bpm
/
/
MD NP/PA RN MA RC
NN
/
/
/
bpm
/
/
MD NP/PA RN MA RC
NN
/
/
/
bpm
/
/
MD NP/PA
RN MA RC
NN
/
/
/
bpm
/
/
MD NP/PA
RN MA RC
NN
/
/
/
bpm
/
/
MD NP/PA RN MA RC
NN
/
/
/
bpm
/
/
MD NP/PA RN MA RC
NN
/
/
/
bpm
/
/
MD NP/PA RN MA RC
NN
/
/
/
bpm
/
/
MD NP/PA RN MA RC
NN
/
/
/
bpm
/
/
MD NP/PA RN MA RC
NN
/
/
/
bpm
/
/
MD NP/PA RN MA RC
NN
/
/
/
bpm
/
/
MD NP/PA
RN MA RC
NN
/
/
/
bpm
/
/
MD NP/PA
RN MA RC
NN
/
/
/
bpm
/
/
MD NP/PA RN MA RC
NN
/
/
/
bpm
/
/
MD NP/PA RN MA RC
NN
/
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/
bpm
/
/
MD NP/PA RN MA RC
NN
/
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/
bpm
/
/
MD NP/PA RN MA RC
NN
/
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/
bpm
/
/
MD NP/PA RN MA RC
NN
/
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/
bpm
/
/
MD NP/PA RN MA RC
NN
/
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/
bpm
/
/
MD NP/PA RN MA RC
NN
/
/
/
bpm
/
/
MD NP/PA RN MA RC
NN
/
/
/
bpm
Study ID
Site #
Reviewer ID
G:\CAATCH\Assessments\Chart Review
4
Current Medications:
Drug Name
Rx Date
Dose
Frequency
Blood Pressure/CVD
/
/
1.
/
/
2.
/
/
3.
/
/
4.
/
/
5.
/
/
Cholesterol
/
/
1.
/
/
2.
/
/
3.
/
/
4.
/
/
Non-CVD
/
/
1.
/
/
2.
/
/
3.
/
/
4.
/
/
5.
/
/
6.
/
/
7.
/
/
Clinical Care Tools:
31.
Self-Management Goals Form
____None
____Present, not signed by MD
____Present, signed by MD
Comments:
Study ID
Site #
Reviewer ID
G:\CAATCH\Assessments\Chart Review
5
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