Babies First and Maternity Case Management Programs Records Review
Date: /Babies First!
/Maternity Case Management
Chart identifier / Chart identifierI. Identifying information (face sheet) (Quality assurance)
1. Client name
2. Birth date
3. Address
4. Parents’ names and address
5. Phone number
6. Household members’ birth dates
7. Emergency contacts
8. Health care provider name and phone number
9. Other agencies serving, contact namesand phone numbers
II.General charting expectations (Quality assurance, except where noted)
1. Entries in chronological order.
2. Each entry dated and signed with title.
3. Each page identified with client name and birth date.
4. Entries legible.
5. All entries typed or in ink.
6. Entries are not altered in any way.
7. Errors marked through with one line and initialed.
8. If spaces are left open, they are marked through and initialed or signed.
9. Use of approved abbreviations only (yearly update).
10. Pages are numbered.
11. “Continued” is written at the end of first page for entries that continue to another page. Continuation is noted on second page. Entries on both pages are signed.
12. An up-to-date record of initials, names, and titles kept on file.
13. Chart is clear and easy to read.Charts are assembled in a consistent manner across agency program.
14. Entries are completed in a timely manner.
15. If records leave the building, a written policy is in place that specifies the agency’s practice regarding secure transportation of medical records.
Confidentiality Reference
16. Medical records in facility are secured. Measures are in place to maintain security of medical records. (Compliance issue)
CLHO Minimum Standards 7.2
III.Nursing Documentation (Compliance issues and quality assurance) (Note type of forms used to document assessments, plans, and outcomes.)
1. Initial entry includes referral source and reason for referral (Quality assurance)
2. Each entry is dated with the type of visit (e.g., HV, TC, TCM) (Quality assurance)
3. Use of S-O-A-P format (Quality assurance)
4. Subjective data documented (Concise, pertinent, description of situation as client sees it which could include information from neighbors, relatives, and friends.)(Compliance issue) OAR 851-045-0060 (2)
5. Objective data documented (Factual information that may include laboratory data, positive and/or negative physical findings, or descriptions of observed client behaviors.)
(Compliance issue)OAR 851-045-0060 (2)
6. Assessment documented (An integration and analysis of subjective and objective data leading to problem identification.)
- Problems related to assessment
- Problems identified using nursing diagnosis or other objective language
- Problems dated
- Resolution dated
7. Nursing Care Plan established (Pending or planned interventions and evaluation of outcomes.)
- Interventions clearly linked to assessment and nursing diagnosis
- Interventions include activities completed during current visit and activities planned for future visits
- Plan outcomes are noted and used to reassess and revise plan of care. (evaluation)
- Babies First! clients have a Nursing Care Plan, in addition to TCM plan.
IV. Targeted Case Management for Babies First! (Compliance issues)
1. TCM visit is clearly documented in Progress Notes.OAR 410-138-0060 (11)(c)
2. State MCH program TCM Assessment and Plan document is completed appropriately at initiation of services. For agencies using an EMR, all components of the TCM Assessment and Plan form are captured and retrievable.
OAR 410-138-0060 (11)(c)
3. TCM Plan is reviewed at each TCM visit and revised, as necessary. At a minimum, TCM Plan is revised annually. OAR 410-138-0060 (11)(c)
4. TCM Visit form is completed for each TCM visit, documenting TCM activities. For agencies using an EMR, all components of the TCM Visit form are captured and retrievable. OAR 410-138-0060 (11)(c)
5. Nurse Case Manager case conferences with Community Health Workers assigned to case and co-signs all TCM Visit forms.OAR 410-138-0060 (11)(b)
V. Babies First! (Compliance issues and quality assurance)
1. High Risk Infant Tracking Flow Sheet
(Quality assurance)
2. Growth Grids (height, weight & head circumference consistently documented and ratios plotted) (Compliance issue)OAR 410-138-0060 (11)(c)
3. Screening Tools (administered according to schedule; tools scored)
(Compliance issue)OAR 410-138-0060 (11)(c)
VI. Maternity Case Management (Compliance issues)
1. Initial Assessment includes development of a Client Service Plan (CSP) that addresses all identified problems (Optional Form DMAP 2470)
OAR 410-130-0595
- Client’s goals and activities are documented
- Nurse/case manager interventions are documented
2. Initial Assessment documents the forwarding of required information to prenatal care providers and others, as indicated.OAR 410-130-0595 / 2.
3. Record documents the following:
a.Implementation of Client Service Plan (CSP) during first Case Management Visit (CMV) / 3a.
b.Face-to-face client contacts during MCM service period / 3b.
- Provision of all mandatory teaching topics
- At least two teaching topics and update and/or revision of CSP for each CMV
- Use of the “5A’s” brief intervention protocol for addressing tobacco use
f.High risk status for client with more than four CMVs / 3f.
- Reasons for repeat Home Assessment (HA), if client had more than one HA
OAR 410-130-0595 / 3g.
4. MCM Nurse Case Manager case conferences with Community Health Workers assigned to case; documents this activity.
(Compliance issue)OAR 410-130-0595 (6)(d)
Additional notes
Babies First! / Maternity Case Management
OHA Public Health Division, Maternal Child Health, Center for Prevention and Health PromotionLE9804b Updated: 01/05/2009; Revised 03/26/12, 09/10/12
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