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					                                                                                     WV PERT RECORDS REVIEW

Directions:

    1. Gather documents needed:
              o      SBHC Bench Marks for WVPERT
              o     Chart Audit Forms for WV PERT

    2. Select one (1) SBHC Bench Marks for WVPERT that your SBHC wants to focus on. The choices include:
              o        Comprehensive Physical Exams
              o        Access to Comprehensive Physical Exams
              o        Adolescent Immunizations
              o        Yearly Blood Pressure, Height, Weight and BMI
              o        Type 2 Diabetes Screening
              o        Written Asthma Action Plan
              o        Poor School Performance
              o        Depression

    3. Review the Chart Audit Form for the selected Bench Mark plus (+) the General Chart Audit Form and the Billing and Coding form .

    4. Select ten (10) charts to audit based on the Bench Mark chosen. The sample of charts selected for review should represent:
               o         the composition of enrolled students
               o         reflect the proportion of males and females by age range
               o         include the range of visit types
               o        information for current school year only

    5. Complete the Chart Audit Form for the both the General and the Billing and Coding forms for the ten (10) charts.

    6. Complete the Chart Audit for the selected Bench Mark. Chart audits may be divided among staff members according to their expertise.

     7. Use the Comments/Explanation Section for further detail. If the comment pertains to a particular chart, please identify the chart number. General comments require no specific chart identification.

     8. Measure your SBHC chart audit rating utilizing the SBHC Bench Marks for WVPERT – Score Key . This is the last column on the form and will be automatically calculated..

    9. Set your SBHC goals for improvement of the selected Bench Mark and time frame for follow up. Next year you will be asked to re-audit your selected Bench Mark.

    10. Each year a new Bench Mark will be chosen and the Bench Mark from the previous year will be re-audited to determine what improvements have been made.

     For questions call Nell Phillips or Joan Skaggs at WVDHHR/OCHS & HP - Division of Primary Care call (304)558-4007
                                                                                                  Benchmarks




  Bench Mark               State Goal           Resources Needed to Implement                                                    Method of Measure                         Score Key
General             90% of charts include 1. Medical charts                                                                  Random audit of 10 charts      1 = 0-1 Charts with all elements
                    all elements on General 2. General Chart Audit Form                                                                                     2 = 2-3 Charts
                    chart audit form                                                                                                                        3 = 4-5 Charts
                                                                                                                                                            4 = 6-7 Charts
                                                                                                                                                            5 = 8-9 Charts
                                                                                                                                                            5 = 10 Charts
Physical            90% physical exams         1. Physical space that is adequate and provides for confidentiality           Random audit of 10 charts of   1 = 0-1 Charts with all critical elements
Examinations are    include all critical       2. Parental consent for physical exam risk assessment tool                    students who have received     2 = 2-3 Charts
Comprehensive       elements according to                                                                                    physical exam
                                               3. WV SBHC resource tool for CPE                                                                             3 = 4-6 Charts
                    WV HealthCheck (see
                                               http://www.wvsbha.org/muta/ta_evaluation_Toolkit_CQ.php                                                      4 = 7-8 Charts
                    chart audit tool)
                                                                                                                                                            5 = 9-10 Charts
*Access to          At least 80% of          *CPE is considered completed as long as documentation exists that it has been   Random audit of 10 charts of    1 = 0 charts of students documented CPE
Comprehensive       students enrolled in the done i.e. at the Medical Home/PCP or SBHC                                       enrolled students who have been
Physical Exams      SBHC have a CPE                                                                                          seen at SBHC within past year 2 = 1 chart
(CPE)               including a risk                                                                                                                         3 = 2 charts
                    assessment every year.                                                                                                                   4 = 3 charts
                                                                                                                                                             5 = 4 or more charts
Up-to-Date          At least 90% of            1. Immunization schedule                                                      Random audit of 10 charts.      1 = 0-2 Charts UTD &/or IP
Adolescent          students utilizing SBHC    2. Most recent Immunization Schedule at                                                                       2 = 3-4 Charts UTD &/or IP
Immunization        services have              http://www.wvimmunization.org/                                                                               3 = 5-6 Charts UTD &/or IP
Ages 11-21          documentation in their
                    charts of up-to-date       3. WV SBHC resource tool for immunizations-                                                                  4 = 7-8 Charts UTD &/or IP
                    immunizations              http://www.wvsbha.org/muta/ta_evaluation_Toolkit_CQ.php                                                      5 = 9-10 Charts UTD
Yearly Blood        At least 90% of            1.Blood Pressure Cuff appropriate for body size.                              Random audit of 10 charts      1= 0-2 charts with yearly blood pressure,
Pressure, Height,   students utilizing SBHC                                                                                  looking at visit information   height, weight, and BMI
Weight and BMI      services have       2. The chart of normal Blood Pressures for height percentile, age, and gender        from the previous 12 months.   2= 3-4 charts
                    documentation in their
                                        3. Bright Futures http://brightfutures.aap.org/                                                                     3= 5-6 charts
                    charts of a yearly blood
                                        4. Standard height for weight charts and CDC Standard Growth Charts with BMI                                        4= 7-8 charts
                    pressure reading,   calculations (may be downloaded from CDC website: www.cdc.gov/growthcharts                                          5= 9-10 charts
Type 2 Diabetes     100% weight, BMI
                    height,of students  1. American Academy of Pediatrics Child and Adolescent Overweight and            Random audit of 10 charts of       1=0-2 charts met criteria for screening
Screening       appropriately screened Obesity                                                                           students who have a BMI >          and had appropriate follow-up
                for type 2 diabetes met http://pediatrics.aappublications.org/cgi/content/full/120/Supplement_4/S163/DC1 85%
                                        2. CDC Standard Height and Weight Charts with BMI calculation & BMI charts                                          2=3-4
                the criteria for        www.cdc.gov/growthcharts
5TH - 12TH      screening and had       3. Ability to collect laboratory specimens or referral source for lab tests                                         3=5-6
GRADE & Ages 10 follow-up if indicated. 4. Specialty practice(s) for referrals                                                                              4=7-9
and older                               5. Additional resource: Prevention, Intervention, and Treatment Strategies for                                      5=10
                                               Primary Care, AAP 2007




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                                                                                                     Benchmarks




   Bench Mark               State Goal           Resources Needed to Implement                                                              Method of Measure                          Score Key
Written Asthma       90% of students with        1. NHLBI Guidelines for the Diagnosis and Management of Asthma (2007)                 Random audit of 10 charts of    1 = 0-2 charts have asthma plan
Action Plan          asthma who utilize          www.nhlbi.nih.gov/guidelines/asthma                                                   students identified with asthma 2 = 3-4 charts
For Asthmatics       SBHC services have a        2. Sample Asthma Action Plan Forms                                                                                    3 = 5-6 charts
                     written asthma action       3. Asthma Action Plan Critical Elements:                                                                              4 = 7-8 charts
                     plan, which is reviewed     A. Severity rating i.e. Green, yellow and red zones defined by symptoms and/or                                        5 = 9-10 charts
                     annually, in their chart    child’s spirometry/peak flow value.
                     and documentation of        B. Type, dose and frequency of prevention and rescue medications listed.
                     the influenza vaccine       C. Instruction on when to seek medical care.
Poor school          90% of past 12
                     over thestudents who        1. Policy regarding communication and collaboration with school administration,       Random audit of 10 charts of       1 = 0-6 charts have documentation of
performance          utilize SBHC                school nurse, counselor, social worker, school psychologist and faculty               students identified with poor      poor school performance
assessment           behavioral health           2. SBHC staff on the school-based Early Intervention Team                             school performance                 2 = 0-9 charts have documentation of
                     services that have been                                                                                                                              poor school performance and 50%
                     assessed as poor school                                                                                                                              assessed with difficulties have been
                     performers have also                                                                                                                                 assessed for medical, behavioral and
                     been assessed for                                                                                                                                    mental health problems
                     medical, behavioral and     3. Identified list of performance indicators from school: lack of interest, trouble                                      3 = Above with 51-95% with difficulties
                     mental health problems      getting homework done, behavioral problems, dropping grades, failing two or                                              assessed as above
All Grades           and have a documented       more subjects, poort attendance/skipping school and suspension from school
                                                 4. Name of school counselor for each student                                                                             4 = Above with >95% assessed
                     plan and referral for
                                                 5. Information regarding absences and discipline                                                                         5 = Above (#4) plus >75% have evidence
                     academic services.
                                                                                                                                                                          of plan and referral for academic services
Depression           90% of students             1. Confidentiality protocol                                                           Random audit of 10 charts of       1 = 0-5 charts have documented
screening and        receiving SBHC                                                                                                    students identified as at high     screening, referral and follow-up
treatment            services have been          2. Guidelines for parental consent                                                    risk of depression                 2 = 6-7 charts as above
All Grades           screened for                3. Standardized depression screening inventory(e.g. CDI, PSC)                                                            3 = 8-9 charts as above plus 1-9 charts
                     depression. 90% of                                                                                                                                   document safety plan and referral for
                     those at high risk have a                                                                                                                            suicide assessment
                     documented safety plan      4. Access to qualified behavioral health provider                                                                        4 = Above plus 10 charts document safety
                     and referral for suicide                                                                                                                             plan and referral for suicide assessment
                     assessment.                 5. Access to psychiatric consult                                                                                         5 = 10 charts document both follow-up
                                                 6. Diagnostic assessment                                                                                                 and a safety plan and referral for suicide
                                                 7. Referral guidelines                                                                                                   assessment
                                                 8. Follow-up protocols
                                                 9. Suicide contract/safety plan
Billing and coding   80% of services             1. Current year CPT book                                                              Random audit of 10 charts per      1 = 0-2 charts correctly coded and billed
accuracy             performed correctly         2. Current year ICD-9 book                                                            provider of students seen in the   2 = 3-4 charts correctly coded and billed
                     coded and billed            3. Current year HCPCS book                                                            SBHC within the current            3 = 5-6 charts correctly coded and billed
                     according to                4. Evaluation and Management coding guidelines (incl)                                 calendar year                      4 = 7-8 charts correctly coded and billed
                     documentation of the
                                                 5. Patient medical record                                                                                                5 = 9-10 charts correctly coded and billed
                     provider in the chart
                                                 6. Charge slip or electronic counterpart
                                                 7. Billing record




                                                                                                      Page 3 of 15
                                                                            Definitions


Medical Chart Audit Definitions


 1. Chart ID#: Site specific chart identification number. For example last four digits of Social Security number.
 2. Chart audit is done on entire chart .
 3. Full chart information: Refers to what should be completed when reviewing the entire chart.
 4. Consent form: The following information can be retrieved from the consent form in the chart.
   a. Consent signed by parent/guardian in chart: Consent form is current, signed by parent/guardian and present in the chart.
   b. Signature witnessed/verified: Consent form contains witness/verification signature, i.e., either the signature of a witness or verification by SBHC staff
      that parent/guardian actually signed the consent form (verification can be done by phone).
   c. Date of birth: Date of birth of the student is available on the consent form.
   d. Grade: Grade of the student is available on the consent form, annual update to consent form, or problem list. This will let you know if the current grade
      is available on the consent form (or update or problem list).
   e. Insurance status.
 5. Name of Medical Home/PCP documented: Name of Medical Home/PCP must be documented in chart if there is one, if none, document that.
 6. All pages contain client identification: Must include name and second identifier (may be date of birth, chart #, Student ID #, last four digits SS #, etc.).
 7. All entries are clear, legible, dated and signed: Each entry is dated and signed.
 8. Allergies are prominently displayed: On problem list in chart and on the front of the chart and must be consistent with the information on the chart.
 9. Problem list: List of the patient’s reasons for presenting including date and diagnosis.
 10. Progress notes: The following information can be found in the progress notes of the chart.
 11. Documentation of collaboration with Medical Home/PCP: Must document all collaboration with Medical Home/PCP.
 12. Resolution documented : If indicated, resolution of problem documented in chart within a reasonable time frame based on generally accepted standard
     of care.
 13. Documentation of follow-ups and results of external referral : Follow-up in progress note/only referral to outside agency (usually has up to six weeks
     to complete). This is documented by the provider. Document whether or not referral appointment was kept. If kept, document results/outcome
     of visit. If not kept, document alternate plan.
                                                                                  General Chart Audit                               Score 1 point for Yes and 0 points for No.
                                                                                                                                    Refer to KEY to determine Section Score.


                                           ITEM                                                              VALIDATION                                       SCORES




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Chart audit is done on entire chart                                                                                                                       0
All medical charts must include:
FULL CHART INFORMATION:
1. Consent form:
      a. Consent signed by parent/guardian in chart
      b. Signature witnessed/verified
      c. Date of birth
      d. Grade
      e. Insurance type listed and current within 12 months
2. All pages contain client identification (name and 2nd identifier)
3. All entries are clear, legible, dated, signed
4. Allergies are prominently displayed
5. Problem list (date and diagnosis documented)
PROGRESS NOTES:
1. Each progress note contains the purpose of visit , assessment and plan
2. Resolution documented (if applicable)
3. Documentation of follow-ups and results of external referral
COLLABORATION WITH MEDICAL HOME/PRIMARY CARE PROVIDER:
1. Medical Home/Primary Care Provider documented in chart
2.Consent contains permission for bi-directional information sharing between Medical
Home/PCP, School Nurse & SBHC
3. Documentation of collaboration with Medical Home/PCP
SCORE (only the 1's count)                                                                   0   0   0   0     0   0        0   0     0      0            0

                                           KEY
            CHART SCORE                =          SECTION SCORE
                  0-2                 =                 1
                  3-4                 =                 2
                  5-6                 =                 3
                  7-8                 =                 4
                  9-10                =                 5
SBHC Provider Name (Please print)
Reviewer Name (Please print)                                                                                        Title
Signature                                                                                                           Date
                                                                                              Billing and Coding
                                                                                                                                              Score 1 point for Yes and 0 points for No.
                                                                                                                                              Refer to KEY to determine Section Score.

                                     ITEM                                                                          VALIDATION                                SCORES




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BILLING AND CODING-10 charts                                                                                                                              0

  1. Provider notes are either on forms or electronic

  2. Forms are appropriate to the SBHC practice

  3. The forms identify coding elements

  4. The provider utilizes the form appropriately

  5. Every note begins with a chief complaint (reason for today’s visit)

  6. All patients are identified as either new or established

  7. The billing form was updated with current CPT, HCPC and ICD-9 codes

  8. The provider chose the correct level of E/M service according to CPT
  coding requirements
  9. The provider chose the correct ICD-9 (diagnosis) codes

  10. The provider linked the diagnosis codes to the appropriate procedure (CPT)
  codes
  11. The provider or staff member marked all services performed on the billing
  form
  12. All ancillary/diagnostic services billed were mentioned in the note as well
  as the reason for the service
  13. All ancillary/diagnostic services billed were actually utilized in diagnosing
  or treating the patient


  SCORE - add only the "1s"
                                                                                      0   0          0       0      0      0      0   0   0   0           0

ALL GRADES


                                       KEY
            CHART SCORE                 =           SECTION SCORE
                   0-2                 =                  1
                   3-4                 =                  2
                   5-6                 =                  3
                   7-8                 =                  4
                  9-10                 =                  5
SBHC Provider Name (Please print)
Reviewer Name (Please print)                                                                                              Title
Signature                                                                                                                 Date
                                                                                              Comprehensive Physical Exam
                                                                                                                                                    Score 1 point for Yes and 0 points for No.
                                                                                                                                                    Refer to KEY to determine Section Score.
                                          ITEM                                                                          VALIDATION                                           SCORES




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PHYSICAL EXAMINATIONS ARE COMPREHENSIVE - 10 charts                                                                                                                      0

Physical exams include:

      1. Parental consent
      2. * Physical examinations contain all the critical elements of WV
HealthCheck Exam including a risk assessment
           a. Statement of reason for visit (i.e. comprehensive physical exam)
           b. *Medical history
               c. * Nutritional history
           d. *Family history

           e. *Social history
           f. Complete physical exam including:
               *Height, weight, BMI growth chart
               *Vital signs (blood pressure, pulse, temperature, respirations)
               *Vision and hearing screening within the past 2 years
               *Dental screening
               *Immunization screening
               *Other screenings as indicated: scoliosis, TB, lead, reproductive
               *Laboratory work, if indicated
               *Behavioral / Mental Health Screen
               *Assessment (summary of findings, indication of good health)
               *Plan of care including referral if indicated
               Screen for diabetes if indicated for Type II, grades 5-12
SCORE - add only the "1s"                                                                 0       0       0       0         0    0      0   0   0            0           0


ALL GRADES


                                            KEY
            CHART SCORE                    =      SECTION SCORE
                  0-2                     =             1
                  3-4                     =             2
                  5-6                     =             3
                  7-8                     =             4
                  9-10                    =             5
SBHC Provider Name (Please print)
Reviewer Name (Please print)                                                                                                    Title
Signature                                                                                                                       Date
                                                                                      Access to Comprehensive Physical Exam



                                    ITEM                                                                               VALIDATION                              SCORES




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ACCESS TO COMPREHENSIVE PHYSICAL EXAMS - 10 charts                                                                                                          0
Verify that student has visited the SBHC within the past 12 months (only assess
charts that a visit within 12 month has occurred)
Documentation exists that the Comprehensive Physical Exam was completed (i.e.
at the Medical Home/PCP or SBHC)
SCORE - add only the "1s"
                                                                                  0        0         0         0          0    0      0   0   0   0         0



ALL GRADES


                                     KEY
            CHART SCORE               =        SECTION SCORE
                  0-2                =               1
                  3-4                =               2
                  5-6                =               3
                  7-8                =               4
                  9-10               =               5
SBHC Provider Name (Please print)
Reviewer Name (Please print)                                                                                                  Title
Signature                                                                                                                     Date
                                                                                      Type II Diabetes Screening
                                                                                                                                              Score 1 point for Yes and 0 points for No.
                                                                                                                                              Refer to KEY to determine Section Score .
                                     ITEM                                                                          VALIDATION                                      SCORES




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TYPE 2 DIABETES SCREENING – 10 CHARTS - students with BMI >
                                                                                                                                                                0
85%
> 85%BMI

           Identified as at risk for diabetes

           Focused family history in medical record (obesity, Type 2 diabetes,
           CV disease, early death from heart disease or stroke)


           Fasting Lipid Profile


           SCORE - add only the "1s"                                              0     0        0       0          0      0      0   0   0         0           0
OR…
85-94% with family risk factors

           Fasting Lipid Profile

           ALT and AST

           Fasting Glucose


           SCORE - add only the "1s"                                              0     0        0       0          0      0      0   0   0         0           0
OR…
> 95% with family risk factors

           Fasting Lipid Profile

           ALT and AST

           Fasting Glucose

           BUN and Creatine

           SCORE - add only the "1s"                                              0     0        0       0          0      0      0   0   0         0           0


                                       KEY
            CHART SCORE                 =       SECTION SCORE
                   0-2                 =              1
                   3-4                 =              2
                   5-6                 =              3
                   7-8                 =              4
                  9-10                 =              5
SBHC Provider Name (Please print)
Reviewer Name (Please print)                                                                                              Title
Signature                                                                                                                 Date
                                                                                      Adolescent Immunizations                          Score 1 point for Yes and 0 points for No.
                                                                                                                                        Refer to KEY to determine section Score.


                                     ITEM                                                                        VALIDATION                                         SCORES




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ADOLESCENT IMMUNIZATION - 10 CHARTS                                                                                                                             0

Immunizations are up to date. (See current Immunization schedule at
http://www.wvimmunization.org/ )
     Tetanus, Diphtheria, Acellular Pertussis (Tdap)

     Hepatitis B

     Varicella (chicken pox)

     Measles, Mumps, Rubella (MMR)

     Influenza (Seasonal Flu)

     Meningococcal

     Human Papillomavirus (HPV)

Immunizations entered in WVSIIS at http://www.wvimmunization.org/

SCORE - add only the "1s"
                                                                                  0     0       0       0        0       0      0   0   0         0             0




11 – 21 YEARS OLD



                                      KEY
            CHART SCORE                =         SECTION SCORE
                    0-2                =               1
                    3-4                =               2
                    5-6                =               3
                    7-8                =               4
                   9-10                =               5
SBHC Provider Name (Please print)
Reviewer Name (Please print)                                                                                            Title
Signature                                                                                                               Date
                                                                                            Annual Vitals
                                                                                                                                       Score 1 point for Yes and 0 points for No.
                                                                                                                                       Refer to KEY to determine Section Score.
                                     ITEM                                                                       VALIDATION                                     SCORES




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YEARLY BLOOD PRESSURE, HEIGHT, WEIGHT AND BMI - 10 charts
                                                                                                                                                             0
Height

Weight

BMI with % plotted

Screening for elevated blood pressure using the chart of normal BPs for height
percentile, age, and gender
If BP elevated, followed ASHI Best Practice for Blood Pressure

SCORE - add only the "1s"
                                                                                    0   0       0           0    0      0      0   0   0         0           0



ALL GRADES


                                       KEY
            CHART SCORE                 =          SECTION SCORE
                    0-2                 =                1
                    3-4                 =                2
                    5-6                 =                3
                    7-8                 =                4
                   9-10                 =                5
SBHC Provider Name (Please print)
Reviewer Name (Please print)                                                                                           Title
Signature                                                                                                              Date
                                                                                               Asthma Action Plan                       Score 1 point for Yes and 0 points for No.
                                                                                                                                        Refer to KEY to determine Section Score.




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ASTHMA – 10 CHARTS                                                                                                                                            0

Students identified with asthma have a written asthma action plan in the chart with:

   1. Severity rating i.e. green, yellow and red zones defined by symptoms and/or
   child’s peak flow value
   2. Type, dose, frequency and route of preventative medications listed

   3. Type, dose, frequency and route of rescue medications listed

   4. Instruction on when to seek medical care

Documentation that action plan has been written or reviewed in the last 12 months

Documentation of the influenza vaccine over the past 12 months

SCORE - add only the "1s"
                                                                                       0   0          0       0     0    0      0   0   0         0           0




ALL GRADES



                                       KEY
            CHART SCORE                 =          SECTION SCORE
                    0-2                 =                1
                    3-4                 =                2
                    5-6                 =                3
                    7-8                 =                4
                   9-10                 =                5
SBHC Provider Name (Please print)
Reviewer Name (Please print)                                                                                            Title
Signature                                                                                                               Date
                                                                                             Depression Screening and Treatment
                                                                                                                                                        Score 1 point for yes and 0 points for No.
                                                                                                                                                        Refer to KEY to determine Section Score.
                                     ITEM                                                                                 VALIDATION                                            SCORES




                                                                                                                                                                                                    E
                                                                         Chart ID#




                                                                                                                                                                                                   R
                                                                                                                                                                                  E




                                                                                                                                                                                                   O
                                                                                                                                                                                 R




                                                                                                                                                                                                 SC
                                                                                                                                                                                O
                                                                                                                                                                              SC




                                                                                                                                                                                             N
                                                                                                                                                                                             O
                                                                                                                                                                            T




                                                                                                                                                                                          TI
                                                                                                                                                                           R
                                                                                                                                                                          A




                                                                                                                                                                                         C
                                                         Present Grade of Student




                                                                                                                                                                         H




                                                                                                                                                                                      SE
                                                                                                                                                                        C
BEHAVIORAL HEALTH – DEPRESSION - 10 charts                                                                                                                                    0

  1. A standardized depression screening is documented

  2. Students at high risk for depression have a documented referral to a qualified
  behavioral health provider in the SBHC, school or community
  3. Students at high risk for depression have documentation of follow up

  4. Students at risk of suicide have a documented safety plan

  5. Students at risk of suicide have a documented referral for suicide risk
  assessment
  SCORE - add only the "1s"
                                                                                         0            0          0   0      0         0         0   0   0         0           0

ALL GRADES



                                                                                                           KEY
                                                    CHART SCORE                                                                 SECTION SCORE
                      0-5 have documented screening, referral and follow-up                                                        =1
                      6-7 as above                                                                                                 =2
                      8-9 as above + 1-9 charts document safety paln and referral for suicide assessment                           =3
                      8-9 as above + 10 charts document safety plan and referral for suicide assessment                            =4
                     10 charts document follow-up, safety plan and referral for suicide assessment                                 =5



SBHC Provider Name (Please print)
Reviewer Name (Please print)                                                                                                         Title
Signature                                                                                                                            Date
                                                                                        Poor School Performance Assessment
                                                                                                                                                         Score 1 point for Yes and 0 points for No.
                                                                                                                                                         Refer to KEY to determine Section Score.
                                      ITEM                                                                                  VALIDATION                                           SCORES




                                                                                                                                                                                                     E
                                                                       Chart ID#




                                                                                                                                                                                                    R
                                                                                                                                                                                   E




                                                                                                                                                                                                    O
                                                                                                                                                                                  R




                                                                                                                                                                                                  SC
                                                                                                                                                                                 O
                                                                                                                                                                               SC




                                                                                                                                                                                              N
                                                                                                                                                                                              O
                                                                                                                                                                             T




                                                                                                                                                                                           TI
                                                                                                                                                                            R
                                                                                                                                                                           A




                                                                                                                                                                                          C
                                                       Present Grade of Student




                                                                                                                                                                          H




                                                                                                                                                                                       SE
                                                                                                                                                                         C
BEHAVIORAL HEALTH – POOR SCHOOL PERFORMANCE - 10 charts                                                                                                                        0
  1. Name of school counselor documented

  2. School performance is documented in the medical chart with respect to:

          a. Lack of interest

          b. Trouble getting homework done

         c. Behavior problems

          d. Dropping grades

          e. Failing two or more subjects

          f. Poor attendance / skipping school

          g. Suspension from school

  3. Students at risk for school failure have been assessed for medical or
  behavioral health problems
  4. Students with recent changes or poor school performance have a documented
  plan or referral
  5. Students with recent changes or poor school performance receive follow-up

  6. Information regarding absences and discipline is documented


  SCORE - add only the "1s"                                                             0           0               0   0    0         0         0   0   0         0           0

ALL GRADES


                                                                                                          KEY
                                                   CHART SCORE                                                                   SECTION SCORE
0-6 have documentation of poor performance                                                                                          =1
0-9 as above + 50% assessed w/ difficulties have been assessed for medical, behavioral and mental health problems                   =2
0-9 as above + 6-9 charts assessed as above                                                                                         =3
0-9 as above + 10 charts assessed as above                                                                                          =4
#4 + 8 charts have evidence of plan and referral for academic services                                                              =5


SBHC Provider Name (Please print)
Reviewer Name (Please print)                                                                                                          Title
Signature                                                                                                                             Date
                                                               Comments


                                                                                                      WV PERT Audit Form Comments


COMMENTS:

Chart ID# _________ ________________________________________________________________________________________________________________________________



Chart ID# _________ ________________________________________________________________________________________________________________________________



Chart ID# _________ ________________________________________________________________________________________________________________________________



Chart ID# _________ ________________________________________________________________________________________________________________________________



Chart ID# _________ ________________________________________________________________________________________________________________________________




General Comments: ____________________________________________________________________________________________________________________

				
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posted:10/28/2011
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