Introduction to the Chronic Conditions Data Sheet

The Data Sheet (Partners in Health Community Access Program Data Sheet)  reports the Target Data  transferred from the Adult Health Schedule to CAP IS Coordinator. The Target Data is scanned into the CAP database using the Data Sheet. Designed as a "scan form", this special form allows the scanner to interpret the Target Data quickly and accurately. Only the Data Sheet is sent to CAP IS Coordinator. The Adult Health Schedule remains in the CAP enrollee's medical record.

The Target Data being collected through this form is taken from the Adult Health Schedule. Target Data for tests, procedures or other events that occurred before enrollment were collected at the time of enrollment through the Health History.

A copy of the Adult Schedule or another similar clinic form may be used in place of this Data Sheet; however, the Target Data scanned from a source other than the Data Sheet scan form is less readily interpreted properly. If the clinic decides to substitute its own existing form in replacement of the Data Sheet scan form, CAP IS Coordinator must be contacted to work with the clinic's staff to ensure that the Target Data is properly interpreted and recorded in the CAP database. A copy of the Data Sheet scan form is available from CAP IS Coordinator.

The following instructions have been created for those clinics that collect the Target Data themselves. It is assumed, but not required, that the Adult Schedule will be kept in the CAP Enrollees medical record and that the Data Sheet be used to transmit the Target Data.

 Instructions for Completing the Data Sheet

Print out a copy of the Completed Sample of the Data Sheet. Refer to it as you read these instructions.

The Data sheet reports the Target Data findings for an individual CAP enrollee. Please print one letter or number in each block. Units of measure (i.e., Blood Pressure "mmHg", Peak Flow "l/m", etc.) are assumed and not recorded.

Please use blue or black ink and make firm and legible block letters and numbers. Note the directions at the top, left-hand corner of this form. The scanner is best able to interpret the Target Data when the circles are shaded in as shown.

Report Target Data items that were never previously reported or are out of date.

Immediately under the title "Data Sheet" at the top of the form, record Today's Date (the date the form is prepared). 07/25/2003

On the next line, print your clinic (facility) name: only one letter in each block. COMMUNITY CLINIC, INC.

On the next line, print the CAP enrollee's First and Last Names and the Middle Initial. JANE DOE P

On the next line, print the Social Security Number, the Date of Birth and shade in the circle that represents the gender of the Enrollee.

458-79-2541

11 / 15 / 1957

Female

On the next line, shade in the circle of all those diagnoses that apply to the Enrollee. In the JANE P DOE example.

Diabetes

Asthma

Hypertension

Depression

You have completed the demographic information for the CAP enrollee.

The Preventive Target Data is:

 

1) Mammography

 

2) PAP

 

3) Colonoscopy / Sigmoidoscopy

 

4) Blood in stool

 

5) Reserved for future use

 

6) Pneumonia Shot and

 

7) Flu shot.

Report Target Data items that were never previously reported or are out of date. Shade in the circle that represents your answer. Write in the month as a two-digit number.

For example: JANE P  DOE has a positive Blood in Stool  test on April 17, 2003. This information is found on the Health Schedule by moving down the left-hand column until the heading Blood in stool is located.Transfer this information to the Data Sheet. At the heading Blood in Stool:, fill in the circle marked Yes and record the date as 04 (April)

The Target Data reported for Diabetes is:

 

1) Self-Care Management

 

2) First HemoglobinA1c

 

3) Second Hemoglobin A1c

 

4) Urine test for protein

 

5) Aspirin Use

Only the First and Second Hemoglobin A1cs require both the date of service and the value.

For Example: JANE P  DOE has a First HemoglobinA1c (for the year) test on January 15 of 2003 and results in a value of 7.3 %.  The "%" sign is assumed and not recorded.

Transfer this information to the Data Sheet.. At the heading First HemoglobinA1c., fill in the Value 7.3 and the date as 01 (January).     

The values for Urine test for protein are Yes, No & NA.

In some instances, those with diabetes who are 30 or more 30 years of age should take a daily aspirin. The values for Aspirin are Yes No & NA

For Example: JANE P  DOE has an abnormal urine test for protein on April 17 2003. On this same day, the provider determines JANE P  DOE should not take a daily aspirin. Transfer this information to the Data Sheet. At the heading Urine Test for protein:, fill in the circle marked abnormal and record the date as 04 (April). Transfer this information to the Data Sheet. At the heading Aspirin Use:, fill in the circle marked NA and record the date as 04 (April). At and after this point, Daily Aspirin Use should no longer be reported for this individual.

The Target Data reported for Hypertension is:

 

1) Documented Self-Care Management

 

2) First Blood Pressure

 

3) Second Blood Pressure

Only the First and Second Blood Pressure require both a date of service and value. Separate blocks have been provided to record these Systolic and the Diastolic pressures.

For Example: JANE P  DOE's  First Blood Pressure reading of 143/93 is taken on May 17, 2003.

Transfer this information to the Data Sheet. At the heading First Blood Pressure:, fill in the circle the spaces with the systolic and diastolic values and record the date as 05 (May). This completes the Target Data reporting for the First Blood Pressure reading for one year.

The Target Data reported for Asthma is: 

 

1)  Self-Care Management

 

2)  Severity Assessment

 

3) Anti-inflammatory Medications

 

4) Peak Flow

The Severity Assessment is recorded as Mild Intermittent, Mild Persistent, Moderate Persistent or Severe Persistent.

For Example: On June 25, 2003 a Severity Assessment for JANE P  DOE indicates Moderate Persistent Asthma. Transfer this information to the Data Sheet. At the heading Severity Assessment, fill in the circle marked Moderate Persistent and record the date as 06. This completes the Target Date reporting for Severity Assessment for one year.

The Peak Flow value is not reported

For Example: JANE P  DOE has a Peak Flow test on June 25, 2003 with the result of 1.2 l/m (liters per minute). Transfer this information to the Data Sheet. At the heading Peak Flow, fill in the circle marked Yes and record the date as 06.This completes the Target Data reporting for Peak Flow for one year.

The Target Data reported for Depression is:

 

1) SCM

 

2) Evaluation

None of the Target Data for Depression requires a value.

Care Management Action Report any Care Management Action taken from the Adult Schedule.

Evaluation.

For Example: JANE P  DOE completes the Hospital Anxiety and Depression Scale on May 21, 2003. Transfer this information to the Data Sheet. At the heading Evaluation, fill in the circle marked Yes and record the date as 05. No value is required. The CAP reporting requirements for Evaluation have been met for the year 2003.

Care Management Actions: Transfer any Care Management Actions found on the Adult Health Schedule to the Data Sheet (i.e., PhC - phone calls, Note - notice sent, Apt - appoint scheduled for missed services, etc.)

SF-8 Health Status Survey: Note the month and year the Survey was completed.

YOU ARE DONE!.  Examine your work to see that the latest data has been properly reported. Send the the Data Sheet to the CAP IS Coordinator.