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Safe and Healthy Beginnings

By Joyce Baker,2014-05-20 11:33
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history suggests why infant did not need to be seen by a licensed health care provider within 2 days of discharge (e.g., full-term and bottle-feeding)

Safe and Healthy Beginnings

    Primary Care Practice Chart Review Tool Instructions

The purpose of the chart review is to help identify current performance and areas for

    improvement. Some information may not be clearly documented in the patient‟s chart and may

    be inferred based on other information listed in the chart. While every attempt should be made to

    record data as accurately as possible, the goal in quality improvement data collection is

    usefulness not perfection.

TeleForm Helpful Hints:

    ? Print neatly in Blue or Black ink

    ? Mark inside box with a “X only, do not use any other symbols

    ? Eliminate stray marks from TeleForm

    ? Do not make notes on the form as these will not be included in the data

    ? Align document during fax submission

    ? Follow all skip patterns on chart review TeleForm

    ? Do NOT make copies of the Teleforms. All forms must be printed

    from a computer

Enter Log # on TeleForm that corresponds to log number on the Chart Review Log Sheet (3 digit

    number)

Enter Practice Code on Teleform, this is the pre-assigned number 93 digit)

Enter Chart Review Date on TeleForm, this is the date you are reviewing the chart.

    1. Is this the infant’s first visit to practice since birth?

    This chart review is concerned with the initial visit made to the primary care practice

    following birth. If this is not the infant‟s first visit to the practice since birth, this chart is

    not eligible to review. Please select another chart. Do not fax this form as it does not count

    as one of the charts reviewed.

2. Was infant less than 72 hours of age when discharged from hospital?

    Review the chart to determine infant‟s age at time of hospital discharge. If infant was older

    than 72 hours of age at time of hospital discharge, this chart is not eligible to review. If

    infant‟s age at time of hospital discharge cannot be determined, this chart is not eligible for

    review. Please select another chart. Do not fax this form as it does not count as one of the

    charts reviewed.

3. Was infant’s hospital discharge summary (including information regarding hospital

    assessment for risk of hyperbilirubinemia and breastfeeding) available for the provider

    to review at the time of this visit?

    Answer „yes‟ if there is documentation that the infants‟ hospital discharge summary

    including information regarding hospital assessment for risk of hyperbilirubinemia and

    breastfeeding is available for the provider to review at the time of this visit.

    4. Do hospital records document whether infant was assessed for risk of a problem with

    severe hyperbilirubinemia? (i.e., notation about risk based on assessment of risk factors

    which may or may not include transcutaneous bilirubin (TcB) OR serum bilirubin (TSB))

    Review the hospital records for evidence that risk for severe hyperbilirubinemia was

    assessed. Risk should be assessed using clinical risk factors; answer “yes” if there is

    specific notation about risk, including infant‟s gestational age and breastfeeding

    adequacy (if applicable). Transcutaneous bilirubin (TcB) or serum bilirubin (TSB)

    level may be done as part of risk assessment.

    5. Did more than 2 days elapse from time of hospital discharge until this visit? Determine if more than 2 days has elapsed from time of hospital discharge until today‟s

    visit. Answer “yes” if more than 2 days has elapsed; answer “no” if less than 2 days has elapsed.

    6. If more than 2 days have elapsed since time of hospital discharge, is one of the following true? :

    ? hospital records document why infant did not need to be seen by a licensed

    health care provider within 2 days of discharge

    ? history suggests why infant did not need to be seen by a licensed health care

    provider within 2 days of discharge (e.g., full-term and bottle-feeding)

    ? infant was seen by another licensed health care provider (e.g., home visiting

    nurse, lactation consultant) between discharge from the hospital and this visit

    ? uncertain reason for delay

    ? other (e.g. weekend/holiday, parent reason, etc.); please specify if known

In some cases, the newborn nursery clinician may determine that although child is being

    discharged from hospital before 72 hours of age, there is no need for a follow-up visit

    within 2 days of discharge. This decision should ideally be reflected specifically in the

    chart. It is also possible to check this response if the primary care clinician‟s note suggests why newborn nursery clinician did not order follow-up care within 2 days of discharge. In

    other cases, infant may have been seen by a licensed health care provider within 2 days of

    discharge who is not associated with the primary care practice. In this case, check the third

    box in this item.

    7. Is infant’s weight at this visit documented?

    Answer “yes” if there is documentation of infant‟s weight at this visit. Answer “no” if there is not documentation of infant‟s weight at this visit.

    8. Is infant’s birth weight OR hospital discharge weight documented in the practice chart? Answer “yes” if there is documentation of infant‟s birth weight or hospital discharge

    weight. Answer “no” if there is not documentation of infant‟s birth weight or hospital discharge weight.

    9. Does the chart document the presence or absence of jaundice at this visit?

    Answer “yes” if there is documentation of the presence or absence of jaundice at this visit.

    Answer “no” if there is not documentation of the presence or absence of jaundice at this

    visit.

    10. Is there documentation that the mother is breastfeeding infant?

    Answer “yes” if there is documentation that mother reports she is still breastfeeding infant

    at time of this visit. This includes any breastfeeding, even if formula is also being used.

    Answer “no” if there is not documentation that mother reports she is still breastfeeding

    infant at time of this visit. This includes any breastfeeding, even if formula is also being

    used.

11. Is there documentation that the infant is exclusively breastfed?

    Answer “yes” if there is documentation that the infant is being exclusively breastfed (no

    supplemental formula given to infant). Answer “no” if there is documentation that the

    infant is being fed anything besides breast milk.

    12. Is there documentation that adequacy of breastfeeding was assessed at today’s visit

    (including child’s weight, descriptions of position, latch, milk transfer, feeding

    frequency, and elimination type and frequency)?

    Review chart for documentation of breastfeeding adequacy assessment.

    Assessment of breastfeeding adequacy could have been done by a lactation consultant,

    nurse, physician or other professional trained in breastfeeding adequacy assessment.

    Elements of a formal assessment of breastfeeding adequacy include:

    1. Infant mouth open wide before latch-on

    2. Latch-on that includes the entire nipple and most of the areola

    3. Infant tongue placed under the nipple

    4. Brief pauses in sucking with audible or visible swallowing

    5. Infant breathing coordinated with suck and swallow cycle

    6. On-demand schedule of eight to 12 feedings per 24 hours

    7. Visible movement of temporomandibular joint during active nursing

    8. Mother supports breast with hand (C-hold) throughout feeding

13. Is there documentation that mother was provided contact information for breastfeeding

    questions and support?

    Answer “yes” if there is documentation that mother was provided contact information for

    breastfeeding questions and support.

14. Is there documentation that mother was provided with contact information for licensed

    health care provider with knowledge and skill in breastfeeding management (e.g.

    IBCLC-lactation consultant, nurse, MS, health worker, dietician, etc.)

    Answer “yes” if there is documentation that the mother was provided with contact

    information for licensed health care provider with knowledge and skill in breastfeeding

    management (e.g. IBCLC-lactation consultant, nurse, MS, health worker, dietician, etc.).

15. Is there documentation that mother was provided with name and contact information

    for community or peer support groups for breastfeeding (e.g. WIC peer support person,

    La Leche League Int’l, etc.) Answer “yes” if there is documentation that the mother was provided with name and contact

    information for community or peer support groups for breastfeeding (e.g. WIC peer support

    person, La Leche League Int‟l, etc.).

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