Ehq manual data collection form _ adolescent ambulatory care indicators_cgw_oct_13_2011.xls

eHIVQUAL
Manual Data Collection Form
ADOLESCENT (13-24 years old) PATIENT PROFILE
All Indicators
Note: To ensure that you only need to refer to each patient's medical chart once, please make sure to answer all of the applicable follow-up questions on this form.
NB: ALL REVIEWS FOR SUBMISSION TO THE AIDS INSTITUTE RUN FROM JANUARY 1ST THROUGH
DECEMBER 31ST
1. PATIENT DEMOGRAPHIC INFORMATION (Required)
Manual Data Collection Form - Adolescents 2. VISITS (Required)
WAS THE PATIENT SEEN IN THE CLINIC BEFORE THE BEGINNING OF THE REVIEW PERIOD? LIST ALL VISITS DURING THE REVIEW PERIOD WITH A PRIMARY CARE OR HIV-EXPERIENCED PROVIDER.
IF THE PATIENT SAW AN HIV-EXPERIENCED PROVIDER, MARK THE "EP" BOX 3. HIV MONITORING (Required)
ENTER ALL VIRAL LOAD RESULTS OBTAINED DURING THE Manual Data Collection Form - Adolescents 4. ARV MEDICATIONS (Required)
GIVE THE START AND STOP DATES FOR EACH ARV MEDICATION THE PATIENT WAS ON DURING THE REVIEW PERIOD INCLUDE ALL MEDICATIONS THE PATIENT WAS ON AT THE START OF THE PERIOD. IF A MEDICATION WAS STOPPED, GIVE THE DATE STOPPED.
IF MEDICATION WAS BEGUN PRIOR TO THE REVIEW PERIOD AND YOU DO NOT KNOW THE START DATE, YOU CAN USE ANY DATE BEFORE THE REVIEW PERIOD AS THE 1ST START DATE (FOR EXAMPLE, ENTER 12/31/09 FOR MEDICATION PRESCRIBED BEFORE THE 2010 REVIEW PEIROD).
IF THE APPLICATION CANNOT DETERMINE THE ANSWER BASED ON MEDICATION DATES YOU ENTER, IT WILL ASK THIS QUESTION DIRECTLY: HAD THE PATIENT EVER BEEN ON ART BEFOR THE BEGINNING OF THE REVIEW PERIOD? CLINICAL TRIAL (Deprecated - Please Specify Drug) CLINTRIAL EMTRICITABINE/TENOFOVIR/EFAVIRENZ (ATRIPLAFTC/TDF/EFV ZIDOVUDINE/LAMIVUDINE/ABACAVIR (TRIZIVIR) Manual Data Collection Form - Adolescents 5. ADHERENCE ASSESSMENT (Required)
WAS THE PATIENT EVER ON AN ARV DRUG DURING THE REVIEW PERIOD? IF YES, WAS THE PATIENT'S ADHERENCE ASSESSED DURING THE REVIEW PERIOD? IF QUANTITATIVE, WHAT WAS THE PERCENTAGE? IF QUALITATIVE, WHAT WAS THE LEVEL (EXCELLENT, GOOD, FAIR, OR POOR)? IF YES, WAS THE ADHERENCE PROBLEM ADDRESSED? 6. SUBSTANCE USE SCREENING (Required)
WAS SUBSTANCE USE DISCUSSED DURING THE LAST SIX MONTHS OF THE REVIEW PERIOD? CIRCLE ALL SUBSTANCES USED AND, IF APPLICABLE, MARK THE WAY USED IF INJECTED, WAS SAFE INJECTION/NEEDLE EXCHANGE WAS THE PATIENT IN TREATMENT DURING THE REVIEW PERIOD? IF SUBSTANCE USE WAS NOT DISCUSSED, WAS IT IDENTIFIED AS A RISK AT BASELINE? Manual Data Collection Form - Adolescents 7. MENTAL HEALTH SCREENING (Required)
ENTER DATE OF LAST DEPRESSION SCREEN DURING REVIEW PERIOD: IF SCREENED, WAS TREATMENT FOR DEPRESSION INDICATED? IF REFERRAL INDICATED, ENTER DATE OF LAST REFERRAL: IF REFERRAL WAS MADE, WAS PATIENT SEEN WITHIN 30 DAYS? ENTER DATE OF LAST ANXIETY SCREEN DURING REVIEW PERIOD: IF SCREENED, WAS TREATMENT FOR ANXIETY INDICATED? IF REFERRAL INDICATED, ENTER DATE OF LAST REFERRAL: IF REFERRAL WAS MADE, WAS PATIENT SEEN WITHIN 30 DAYS? ENTER DATE OF LAST PTSD SCREEN DURING REVIEW PERIOD: IF SCREENED, WAS TREATMENT FOR PTSD INDICATED? IF REFERRAL INDICATED, ENTER DATE OF LAST REFERRAL: IF REFERRAL WAS MADE, WAS PATIENT SEEN WITHIN 30 DAYS? ENTER DATE OF LAST COGNITIVE FUNCTION ASSESSMENT (INCLUDING MENTAL STATUS) DURING REVIEW PERIOD: IF SCREENED, WAS TREATMENT FOR COGNITIVE FUNCTION INDICATED? IF REFERRAL INDICATED, ENTER DATE OF LAST REFERRAL: IF REFERRAL WAS MADE, WAS PATIENT SEEN WITHIN 30 DAYS? Manual Data Collection Form - Adolescents 8. INFLUENZA VACCINATION (Required)
MOST RECENT INFLUENZA VACCINATION (DURING OR PRIOR TO THE REVIEW PERIOD) 9. URINALYSIS (Required)
MOST RECENT URINALYSIS (PERFORMED DURING OR PRIOR TO THE REVIEW PERIOD) 10. PATIENT EDUCATION (Required)
MOST RECENT EDUCATIONAL ASSESSMENT (PERFORMED DURING OR PRIOR TO THE REVIEW PERIOD) WAS THE PATIENT SCREENED FOR HEALTH LITERACY DURING THE REVIEW PERIOD? Manual Data Collection Form - Adolescents 11. ADOLESCENT-SPECIFIC INDICATORS (Required)
WAS A COMPREHENSIVE EXAM DOCUMENTED DURING THE REVIEW PERIOD? IF THE PATIENT WAS UNDER 16, WAS THE TANNER STAGE KNOWN AT THE END OF THE REIVEW PERIOD? IF STAGE 1, 2, 3 OR 4, WAS AN ASSESSMENT CONDUCTED DURING THE REVIEW PERIO? DID THE PATIENT RECEIVE ADOLESCENT RISK REDUCTION EDUCATION DURING THE LAST SIX MONTHS OF THE REVIEW PERIOD? DID THE PATIENT PARTICIPATE IN THE DEVELOPMENT AND/OR REVISION OF THE TREATMENT PLAN DURING THE REVIEW PERIOD? WAS A HOUSING ASSESSMENT PERFORMED DURING THE LAST 6 MONTHS OF THE REVIEW PERIOD? WAS A HOUSING ISSUE IDENTIFIED DURING THE REVIEW PERIOD? IF A HOUSING ISSUE WAS IDENTIFIED, WAS IT ADDRESSED? WAS A FAMILY SITUATION ASSESSMENT PERFORMED DURING LAST 6 MONTHS OF THE REVIEW PERIOD? WAS A CRIMINAL JUSTICE SYSTEM INVOLVEMENT ASSESSMENT PERFORMED DURING THE LAST 6 MONTHS OF THE REVIEW PERIOD? WAS AN INSURANCE ASSESSMENT PERFORMED DURING THE LAST 6 MONTHS OF THE REVIEW PERIOD? WAS AN INSURANCE ISSUE IDENTIFIED DURING THE REVIEW PERIOD? IF AN INSURNACE ISSUE WAS IDENTIFIED, WAS IT ADDRESSED? WAS A LIFE SKILLS ASSESSMENT PERFORMED DURING THE LAST 6 MONTHS OF THE REVIEW PERIOD? WAS A VIOLENCE ASSESSMENT (INCLUDING REVIEW OF SITUTATIONS WHERE THE PATIENT MAY HAVE BEEN A VICTIM, WITNESS OR PERPETRATOR) DOCUMENTED DURING THE REVIEW PERIOD? IF A VIOLENCE ASSESSMENT WAS CONDUCTED, WAS THE PATIENT A VICTIM OR PERPRETRATOR OF VIOLENCE? IF PATIENT WAS A VICTIM OR PERPETRATOR OF VIOLENCE, WAS ACTION TAKEN TO FOLLOW UP THE ASSESSMENT, INCLUDING REFERRAL OR TREATMENT IF INDICATED? WAS ASSESSMENT OF SEXUAL ABUSE/SEXUAL ASSAULT DOCUMENTED DURING THE LAST SIX MONTHS OF THE REVIEW PERIOD? WAS SEXUAL ACTIVITY ASSESSED DURING THE FIRST SIX MONTHS OF THE REVIEW PERIOD? WAS SEXUAL ACTIVITY ASSESSED DURING THE LAST SIX MONTHS OF THE REVIEW PERIOD? IF ASSESSED (ANYTIME DURING THE REVIEW PERIOD), WAS THE PATIENT SEXUALLY ACTIVE (PENETRATIVE GENITAL INTERCOURSE) DURING THE REVIEW PERIOD? IF SEXUALLY ACTIVE, WERE THE FOLLOWING ASSESSMENTS PERFORMED? IF YES, DID THE PATIENT ENGAGE IN ORAL-RECEPTIVE SEX DURING THE REVIEW PERIOD? IF YES, DID THE PATIENT ENGAGE IN ANAL-RECEPTIVE SEX DURING THE REVIEW PERIOD? IF YES AND FEMALE, DID THE PATIENT HAVE VAGINAL SEX DURING THE REVIEW PERIOD? Manual Data Collection Form - Adolescents CONTRACEPTIVE HISTORY, CURRENT PRACTICES AND PREGNANCY HISTORY (FEMALE PATIENTS ONLY) (Optional) IF SAFER SEX PRACTICES WERE ASSESSED, WAS CONDOM USE QUANTITATIVELY ASSESSED? IF THE PATIENT WAS MALE OR A SEXUALLY ACTIVE FEMALE (VAGINAL INTERCOURSE DURING THE REVIEW PERIOD), WAS A GENITAL EXAM ("PELVIC EXAM" FOR FEMALES) PERFORMED DURING THE REVIEW PERIOD? IF FEMALE, WAS A PAP TEST PERFORMED DURING THE REVIEW PERIOD? IF THE PATIENT WAS SEXUALLY ACTIVE DURING THE REVIEW PERIOD, DID THE FOLLOWING OCCUR DURING THE REVIEW PERIOD? SYPHILIS SCREENING (EVERY 6 MONTHS FOR MSM) IF HISTORY OF ORAL-RECEPTIVE SEX, PHARYNGEAL GONORRHEA CULTURE IF HISTORY OF ANAL-RECPETIVE SEX, ANAL GONORRHEA CULTURE IF HISTORY OF ORAL-RECEPTIVE SEX, PHARYNGEAL CHLAMYDIA TEST IF HISTORY OF ANAL-RECEPTIVE SEX, ANAL CHLAMYDIA TEST DOES THE PATIENT KNOW HIS/HER HIV STATUS? A IF THE MEDICAL RECORD DOCUMENTS A PERINATALLY INFECTED AND UNAWARE PATIENT, WAS THERE DOCUMENTED DISCUSSION AROUND DISCLOSURE ISSUES BETWEEN PROVIDER AND PARENT(S)/GUARDIAN DURING THE LAST SIX MONTHS OF THE REVIEW PERIOD? B IF THE MEDICAL RECORD DOCUMENTS A BEHAVIORALLY INFECTED AND AWARE PATIENT, HAS PATIENT DISCLOSED HIV STATUS TO PARENT/GUARDIAN/SUPPORTIVE ADULT FIGURE? B2 IF THE PATIENT'S RECORD DOES DOCUMENT DISCLOSURE, HAS THE PROVIDER ASKED WHO THE SUPPORTIVE FIGURE IS AND RELATION TO PATIENT? C IF THE PATIENT WAS DOCUMENTED AS SEXUALLY ACTIVE DURING THE REVIEW PERIOD AND AWARE OF HIS/HER HIV STATUS, HAS THE PATIENT DISCLOSED HIV STATUS TO PARTNER(S)? C2 IF THE PATIENT HAS NOT DISCLOSED STATUS TO PARTNER(S), HAS PARTNER NOTIFICATION COUNSELING BEEN PROVIDED TO PATIENT? Manual Data Collection Form - Adolescents 12. BODY MASS INDEX (Optional)
WERE THE PATIENT'S CURRENT HEIGHT AND WEIGHT RECORDED DURING THE REVIEW PERIOD? IF YES, WHAT WAS THE PATIENT'S HEIGHT (ENTER MOST RECENT VALUE)? IF YES, WHAT WAS THE PATIENT'S WEIGHT (ENTER MOST RECENT VALUE)? FOR TRANSGENDERED PATIENTS (EITHER M->F OR F->M), HOW DO YOU WANT TO ASSESS THE PATIENT'S BMI? 13. DIABETES MANAGEMENT (Optional)
WAS A FASTING BLOOD GLUCOSE LEVEL (FBS) OBTAINED DURING THE REVIEW PERIOD? WAS AN ORAL GLUCOSE TOLERANCE TEST (OGTT) CONDUCTED DURING THE REVIEW PERIOD? WAS AN HBA1C TEST PERFORMED DURING THE REVIEW PERIOD? WERE ANY OF THESE THESHOLD VALUES MET OR EXCEEDED?
14. HYPERTENSION (Optional)
WHEN WAS THE PATIENT'S LAST BLOOD PRESSURE READING? WAS THE PATIENT BEING TREATED FOR HYPERTENSION? BASED ON ABOVE VALUE, WAS THE PATIENT STAGE 2 HYPERTENSIVE (SYSTOLIC >160 OR DIASTOLIC >100)? IF NOT STAGE 2, WAS THE PATIENT STAGE 1 HYPERTENSIVE (NOT STAGE 2, SYSTOLIC > 140 IF THE PATIENT WAS STAGE 1: WAS THE PATIENT TREATED WITH MEDICATION? IF THE PATIENT WA STAGE 2: WAS THE PATIENT TREATED WITH A 2-DRUG COMBINATION? Manual Data Collection Form - Adolescents

Source: http://www.ehivqual.org/scripts/eHQ%20Manual%20Data%20Collection%20Form%20_%20Adolescent%20Ambulatory%20Care%20Indicators.pdf