Documentation Guidelines and Sample Forms

• Patient Visit Forms
• Medical Summary/Child History
• Sample Letters and Forms
• Practice Policy and Procedures

Chronic Care Visit Forms
For physicians to document their patient visits for CSHCN.

• Long Term Care Form
  From Phoenix Pediatrics.
• Chronic Care Visit Form
  From The Center for Infants and Children with Special Needs
  

  Prepping the Chart
  Condition: Go through the chart and progress notes and update new or changed conditions/diagnosis status and medications.
  Followed by: Note the specialist or therapist. Note recent reports related with the date.
  Recent Labs/X-rays: Check chart and ask caregiver when calling to remind them of the visit.
  Weight: Note last weight next to new weight for quick reference.
  Yearly Well Physical Exam Due: Note as a reminder
  
  At the Visit
  Utilize the top demographic section to generate questions. Review all information with patient and family/caregiver and ask for new or changed information.

• How to Make Best Use of Resource Information:
  In a well child visit, here are a list of questions and topics providers should be asking families to assess if they have any needs with home health, durable medical equipment, day care, respite, insurance/financing, school, etc. Utilize local/state resource guides for information to offer families and patients. For local and state specific resources you can go to your state page "Family Corner" by clicking here.
• Documentation Guidelines
  When caring for CSHCN, the use of a standardized progress note may be helpful to document the increased information necessary to deliver care. The appropriate documentation will help justify the Evaluation and Management codes billed for each encounter. Many special needs patients require more time, and are more complex to care for. The attached progress note is one template that can be used to provide the necessary documentation for the E&M codes that are billed for this population. Developed by the Pennsylvania Medical Home Team
• Progress Note
  Developed by the Pennsylvania Medical Home Team

Medical Summary and Child History Information

• Problem Sheet/ Medical History Outline
  A detailed brief outline of significant events in the child’s medical history.
  
  The Problem Sheet improves quality of care and efficiency as it serves several functions… Guides day to day care but it is also what makes for a more efficient and comfortable walk through the rest of the health care system such as ER visits, hospitalization and referrals. Effects time and improves care by giving the physicians and or therapists detailed information because many get over or under-treated because of lack of proper knowledge on their past history. You should keep a current plan of care and the problem sheet as the central record. Since Treatment is ongoing and changes, it should not be on the problem sheet.
  
  
• Child History Fact Sheet
  The "Child History and Fact Sheet" reviews personal information, caregivers/ providers, environmental information, financial/ insurance information, community services, home care services, special issues, etc. Recommended to be kept in the patient's chart in an easily accessible place. Developed by The Center for Infants and Children with Special Needs

Sample Letters and Forms

Referral/Fax Back Forms
• Referral Fax Back Form
• CHMC Emergency Department Referral Fax Form
• Alameda County Medical Home Referral & Feedback Form with Consent
  
  Release Forms
• Release Form—Request for Non-CHMC Medical Records
  
• Release Form—Authorization for Use and/or Disclosure of Protected Health Information to Schools
  
  Office Surveys
• Exeter Pediatric: Office Visit Family “Mini” Survey (Pre-Visit)
• Exeter Pediatric: Family Survey (Post-Visit)
• Exeter Pediatrics: Provider Survey
  
  Defining Medical Necessity and Writing the Letter - Guidelines
  -From the Utah MedHome Portal
  Sample Letters of Medical Necessity
  This site, developed by Dr. John Bach, Professor of Physical Medicine and Rehabilitation and Co-Director of the Jerry Lewis Muscular Dystrophy Association Clinics, offers a variety of sample letters of medical necessity and allows the user to create his/her own letter by filling in the blanks.
  
  How to Write a Letter of Medical Necessity
  Rifton is a company that makes equipment for the disabled. Their website offers assistance in writing letters of medical necessity including a checklist and how to deal with the appeals process. The site also has links to pdf sample letters for bathing systems, toileting systems, supine standers, gait trainers, etc.
  
  A Request for a Letter of Medical Necessity: A form for parents/staff to fill out to aid you in the letter writing process.
  
  The appeals process What to do when the request is denied.
  
  Sample Letters
• Letter to Electric or Gas Company
• Letter of Necessity for Diapers and Wipes
• Letter of Necessity for Equipment
• Letter of Necessity for Formula and Nutrition Supplement
• Letter to School Regarding CYSHCN Health Condition

General Information on Practice Policies and Procedures

• Incorporating Quality Improvement Into Pediatric Practice Management
• Practice Procedures Fact Sheet
• Special Requirements for Electronic Medical Record Systems in Pediatrics

Last updated July 25, 2006