Download Append F 3 – Chart-Interview Note Form

PCBH Program Manual Appendix F3
PCBH Program Chart Note
PCBH PROVIDER (PRINT)
DATE
TIME
CAUTION: Federal and State laws protecting confidential patient information apply to patient information contained in this completed form.
PATIENT INFORMATION (sticker may be affixed)
LAST NAME
FIRST NAME
ALIASES
M.I.
SSN
DOB
MRN
REFERRAL
REFERRING PROVIDER
PC CLINIC
DATE OF REFERRAL
PRIMARY REASONS FOR REFERRAL
ASSIGNED PCP, IF DIFFERENT
TYPE OF PCBH VISIT
 SAME DAY
 INITIAL VISIT
 SCHEDULED  FOLLOW-UP
LAST VISIT (date):
FIRST TIME SEEN BY PCBH PROGRAM:  NO  YES, THEN:
 PCBH SERVICES EXPLAINED  PATIENT GAVE VERBAL CONSENT
 INDIVIDUAL  GROUP/CLASS
 COUPLE  FAMILY  PHONE
IF PATHWAY, FOCUS IS:
1. SUBJECTIVE NOTES
LIFE CONTEXT:
 LIVES WHERE? HOW








LONG? WITH WHOM?
IF HOMELESS, HOW
LONG SINCE PERM
HSD?
LEGAL / CRIMINAL?
WORKS / OBTAINS
ECONOMIC SUPPORT?
FAMILY? FRIENDS?
RELAXATION?
EXERCISE?
FUN?
SOCIAL /
COMMUNITY?
HEALTH /
HEALTH RISK:
 CHRONIC DISEASE(S)?
 ADHERENCE TO




MEDICATIONS
ADHERENCE TO
OTHER TREATMENT?
ETOH / DRUGS?
TOBACCO?
RISK AND SAFETY?
To what extent is (reason for referral) a problem for you?
Scale 1-10: ________
OTHER FACTORS
IMPACTING HEALTH
AND USE OF
HEALTH CARE
SERVICES:
 HISTORY OF HEAD




INJURY
LEARNING DISABILITY
/ ADHD
ACCULTURATION
STRESS
HEALTH LITERACY
CONCERNS
CHRONIC DISEASE

`



TIME?
TRIGGERS?
TRAJECTORY?




WHAT MAKES BETTER?
WHAT MAKES WORSE?
SOLUTIONS TRIED?
RESULTS?
2. OBJECTIVE NOTES
DUKE
TOTAL SCORE
PHYSICAL HLTH
MENTAL HLTH
SOCIAL HLTH
APPEARANCE
 WNL
 OTHER:
PSC-17
PARENT
TOTAL SCORE
PSC-17
YOUTH
COMPARISO
N TO PRIOR
SUGGESTS:
INTERNALIZING
ATTENTION
EXTERNALIZING
BEHAVIOR
 WNL
 OTHER:
INTERNALIZING
ATTENTION
EXTERNALIZING
MOOD
 WNL
 OTHER:

IMPROVEM
ENT
 STABILIZED
 DECLINE
PRIOR SURVEY DATE
 N/A
COMPARISON TO PRIOR SUGGESTS:
 IMPROVEMENT
 STABILIZED
 DECLINE
 N/A
3. ASSESSMENT
BRIEF
INTERVENTIONS
PROVIDED
(reference
checklist):
1.
2.
3.
4. PLAN
RECS TO
PATIENT
1.
2.
1.
RECS TO PCP
2.
Communicated
directly to referring
provider?
 Yes  No
3.
IF INDICATED, FOLLOW-UP
APPOINTMENT WITH PCP (date)
FOLLOW-UP APPOINTMENT
WITH PCBH PROVIDER (date)
IF INDICATED, FOLLOW-UP
APPOINTMENT WITH PCP (date)
REFERRAL MADE TO
 MH CLINIC:
___________________________________________________ APPT:_____________________
 SA PROGRAM:
___________________________________________________ APPT:_____________________
 OTHER (specify):
___________________________________________________ APPT:_____________________
 OTHER (specify):
___________________________________________________ APPT:_____________________
VISIT SCALING
ANSWERS
How confident are you that you can carry out
the plan we’ve made:
Scale 1-10: ________
How helpful
was this visit?
Scale 1-10: ________
Appendix F3-Page 2