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pdfPatient Navigator Outreach and Chronic Disease Prevention Program
Local Identifiers (site use only)
Navigator Encounter Form
Study Data
Tasks
At least one must be checked
Study ID:
Navigator ID:
Encounter Date:
Method
Check one
Telephone
No contact
Home Visit
Other face-to-face (not home visit)
Setting, optional:
Written
Group session
Other
Specify, optional:
Person
Check all that apply
Patient
Social network (family/friends)
Healthcare staff/provider
Social services/community org rep
Other
Specify:
Other (optional)
Topic addressed:
Reason for encounter:
Minutes:
Rev. 19-Sep-2011
Check all that apply
Identify or address barrier
Coordinate health care appt logistics
(patient w/disease only)
Discuss diagnosed disease and
its treatment
Coordinate education & services for
preventive care/early detection
Coordinate health care coverage
Assist with filling Rx or medical
equipment request
Coordinate social services
Link to community organization
Clinical trials notification
Confirm patient status/maintain
relationship
Education re: life skills/selfmanagement
Additional notes (optional)
Barriers
Check all that apply
No barriers identified/addressed
System/Access
No established primary care
Transportation (local)
Location of health care (non-local)
Housing during treatment
System problems with scheduling care
System problems with coordinating care
Lack of access to a specialist
System culture and practices
Staff beliefs and attitudes
Difficult access to appropriate food
Personal
Disability/comorbidity
Unable to care for self at home
Costs: health care
Costs: medication/equipment
Employment issues
Internal psychological (anxiety)
Habitual unhealthy lifestyle
External psychosocial (isolated)
Health literacy/lack of information
Language
Cultural/personal beliefs and attitudes
Lack of reliable communication
Family
Childcare/family care issues
Housing
Other
Other 1
Specify:
Other 2
Specify:
Entered by:
Date:
Navigator Encounter Form (page 2)
Study ID
Notes (local use only)
Updates to Navigated Condition
Navigated Condition
Updates to Coverage (optional)
Pharmacy Assistance Check one
Rev. 19-Sep-2011
Date:
Cancer-related conditions
Check one
Asthma, at risk/pre-asthma
Asthma, diagnosed
CHF, diagnosed
CVD, at risk/family history
CVD, diagnosed
Depression, positive screen
Depression, diagnosed
Diabetes, at risk/family history
Diabetes, pre-diabetes
Diabetes, diagnosed
Gestational diabetes
Hyperlipidemia
Hypertension, positive screen
Hypertension, diagnosed
Obesity (adult)
Obesity (pediatric)
Other:
Cancer, screening
Cancer, abnormal finding
Cancer, diagnosis
No
Yes
Not Available
Entered by:
Type of cancer:
Stage:
0
1
2
3
4
N/A
Optional Information:
Substage:
A
B
C
TNM Staging:
Histology:
Date Associated with New Condition
__ __ / __ __ / __ __ __ __
Entered by:
HC Coverage
Date:
Check all that apply
No coverage
Medicare
Medicaid
IHS
Private insurance
Other Government plan
Single service plan
Reduced-fee/sliding scale
Free care
Other
Specify:
Patient Navigator Outreach and Chronic Disease Prevention Program
Local Identifiers (site use only)
Navigator Characteristics
Details
Language
Gender: Male
Female
Transgender
Primary Language:
(See list below for options)
Birth year:
Additional Languages (Check all that apply)
None
English
Spanish
Chinese
Fijian
Filipino: Ilocano
Filipino: Tagalog
Filipino: Visayan
Filipino: Other
French
Haitian Creole
Hmong
Japanese
Korean
Micronesian: Chuukese
Micronesian: Kosraean
Micronesian: Marshalese
Micronesian: Pohnpeian
Micronesian: Yapese
Mixteco
Navajo
Samoan
Somali
Tongan
Vietnamese
Other
Specify:
Ethnicity: Hispanic or Latino
Non-Hispanic
3-digit zip prefix:
Hired on:
Education
Check one
No formal education
Primary education only
Some HS/secondary education
HS Diploma/GED/other secondary
education
Some college/vocational school/other
post-secondary education
Completed college, post-secondary or
vocational school
Post-college/graduate school
Race
Check all that apply
White
Black/African American
Asian
Native Hawaiian/Pacific Islander
American Indian/Alaskan Native
Optional race coding:
Rev. 19-Sep-2011
Professional Training Check all that apply
None
RN
LPN
Medical Assistant/ Nurses Aide
Social Worker
Phlebotomist
Radiology Technologist
Mammography Technologist
PN certification
Community Health Worker (CHW)
certification
CHW training for specific condition
Workshops/trainings
Certified Medical Interpreter
Alternative Health Care Provider
Other
Specify:
Study Data
Navigator ID:
Entered by:
Date:
Patient Navigator Outreach and Chronic Disease Prevention Program
Local Identifiers (site use only)
Clinical Measures/Lab Form
Study Data
Study ID:
Test Type
NR*
Test/Rx/Visit
Date
No medical record
Reporting Requirements by Navigated Condition
Result(s)
Asthma, at risk/pre-asthma:
Current smoker
Asthma, diagnosed:
Peak Flow, ER/Hospitalization, Albuterol Prescription Date,
Current smoker
Fasting blood glucose
HbA1c
Dilated eye check
Diabetic foot check
CVD, at risk/family history:
Current smoker
Diabetes self-management plan
CVD, diagnosed:
Blood Pressure, ER/Hospitalization, Lipids, Current smoker
Blood pressure
Antihypertensive prescription date
Peak flow
ER/Hospitalization
(record all dates; use back if needed)
Albuterol prescription date
Lipids
Statin prescription date
BMI
Diuretic prescription date
Current Smoker
Other, Specify:
CHF, diagnosed:
ER/Hospitalization, Diuretic Prescription, Current smoker
Systolic:
Depression, positive screen or diagnosed:
Current smoker
Diabetes, at risk/family history, pre-diabetes, or
gestational diabetes:
Current smoker; Fasting Blood Glucose or HbA1c
Diabetes, diagnosed:
HbA1c, Dilated Eye Check, Diabetic Foot Check, Diabetes
Self-management Plan, Blood Pressure, ER/Hospitalization,
Lipids, BMI, Current smoker
HDL:
LDL:
Hyperlipidemia, diagnosed:
ER/Hospitalization, Lipids, Statin prescription date, Current
smoker
Hypertension, positive screen:
Blood Pressure, Current smoker
Hypertension, diagnosed:
Blood Pressure, Antihypertensive Prescription Date,
ER/Hospitalization, Lipids, Current smoker
Yes
No
Obesity, adult or pediatric:
BMI, Current smoker
Cancer, screening, abnormal finding, or diagnosed:
Current smoker
* Not recorded in medical record
Rev. 19-Sep-2011
Diastolic:
Entered by:
Date:
Patient Navigator Outreach and Chronic Disease Prevention Program
Local Identifiers (site use only)
Co-Occurring Disorders
Study Data
Study ID:
Abstraction Date:
List all chronic, co-occurring disorders present for patient at the time of chart review.
Data must be from medical records, not self-reported.
No Medical Record
No Co-Occurring Disorders
Description
Rev. 19-Sep-2011
Notes (local use only)
Entered by:
Date:
Patient Navigator Outreach and Chronic Disease Prevention Program
Local Identifiers (site use only)
Update to Navigation Status
Study Data
Study ID:
Navigator ID:
Status
Check one
In Progress*
Inactive*
Withdrew
Lost
Ineligible
Died
Complete
End of grant (in progress)
End of grant (stable, not complete)
Date (date navigation status changed):
__ __ / __ __ / __ __ __ __
Reason for change in navigation status
(optional):
Closeout only:
Pharmacy Assistance Check one
No
Yes
Not Available
HC Coverage
Check all that apply
No coverage
Medicare
Medicaid
IHS
Private insurance
Other Government plan
Single service plan
Reduced-fee/sliding scale
Free care
Other
Specify:
Other Data Due At Closeout
* Closeout data not required when moving a
patient to a status of In Progress, or
Inactive.
Rev. 19-Sep-2011
Check if complete
VR-12
Co-occurring disorders
Lab
Entered by:
Date:
File Type | application/pdf |
File Title | Slide 1 |
Author | Carmita Signes |
File Modified | 2011-10-03 |
File Created | 2011-09-19 |