Instructions for the Adult Health Schedule
The Adult Health Schedule collects the required preventive and chronic condition Target Data taken from tests, procedures or other events that occurred after the individual enrolled into CAP. Target Data for tests, procedures or other events that occurred before enrollment were collected at the time of enrollment through the Health History. The Health Schedule remains in the CAP Enrollee's medical records. With exception of the Target Data (printed in red) that may not be altered, the clinic may add headings in the blank spaces provided.
All Target Data is transmitted to CAP IS Coordinator at the CAMCARE Health Education & Research Institute (CHERI). For those clinics wishing to use the Adult Schedule, an electronic copy that may be edited by Microsoft Excel is be provided.
Print out a copy of the Completed Sample of the Health Schedule. Refer to it as you read these instructions.
The units of measure used for Target Data are as follows:
|HemoglobinA1c||Blood Pressure mmHg||Peak Flow l/m|
|percent (%)||(millimeters of Mercury)||(liters per minute)|
The unit of measure is assumed but not reported with the value. However, any test value must be converted to the appropriate unit of measure before the value is provided to CAP IS Coordinator for evaluation. If you have any questions, please communicate with CAP IS Coordinator before providing any test value not in these units of measure. Peak Flow values are not reported.
Please use blue or black ink and make firm and legible block letters.
At the right-hand top of this form, write in the Chart # (Medical Record Name or Number) (Optional). JDOE-01
Below the legend (Self-Care Management (SCM) on the left-hand side of this form, in the spaces provided. write in the CAP Enrollee's
|Last Name DOE||First Name JANE||MI P|
|Gender F||CAP Y||DOB 11/15/1957||Social Security Number 458-79-2541|
Note that there are six (6) calendar Year headings across the page beginning with 2002 and ending with 2007. Below and to the right of each Year heading there is a narrow block (blue background color) labeled "mth" (for month). Together the Year column and the month column comprise the date. The day of the month is not required except for the CAP enrollees DOB (Date of Birth).
Under the year heading and alongside the month block is a wider block labeled " VALUE" (has no background color). Place any required values here.
Note that only those Target Data items, (left-most column), whose headings are printed in red require a response to CAP. With two exceptions that do require a value, only the month and year is required. The two exceptions, hemoglobin and blood pressure, do require both a date (month & year) and a value.
Only dates are required for Preventive care headings. The next headings are the Disease Disparities: Diabetes, Hypertension, Asthma and Depression (where a date and value is required as noted). The Self-Care Management goals and any guidance or tools cited within these instructions are for illustration purposes only and their use is not required. The Care Management section is provided for the convenience of the clinic and does not require that any data be reported.
For example: JANE P DOE has a positive Blood in Stool test on April 17, 2003. This information is noted on the Health Schedule by moving down the left-hand column until the heading Blood in stool is located. In the Year 2003 column, the number 04 (April) is recorded in the month block. In the VALUE column, insert a "P" for "Done & Positive" (see the legend at the top right of the page).
There are six preventive Target Data items. Five are currently used and each requires a date. No values are required.
|4) Blood in stool|
|5) Reserved for Future Use|
6) Pneumonia Shot
7) Flu shot.
The heading SCM indicates that Self-Care Management for Diabetes must be documented one time per year. The Self-Care Management legend (top, left-hand side) provides a list of self-care goals for Diabetes. The CAP diabetic must have agreed with the provider to set one or more of these goals for her or him to carry out over the coming year. Documentary evidence of such an agreement may be in the form as in the sample cited. The clinic may have within its medical record or elsewhere any manner of documenting Self-Care Management for Diabetics.
An example of Self-Care Management may be found at the following URL:
Diabetes Goal Contract
The HemoglobinA1c test date and value are required two (2) times per year. There are two headings for HemoglobinA1c. The first heading, First Hemoglobin A1c, is for the first HemoglobinA1c date and value taken after enrollment. The second heading, Second Hemoglobin A1c, is for the second date and value taken after the First and separated in time by at least three (3) months.
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 %. Under the Year 2003 column, write an 01 (January) and 7.3 in the adjacent VALUE column. The "%" sign is assumed and not recorded.
No more First HemoglobinA1c data for JANE P DOE need be reported until on or after January 15, 2004 (i.e., a one year period). Second Hemoglobin A1c is reported separately at another time. A Second Hemoglobin A1c is due one year after it was first performed. This is not a hard and fast rule. At least two HemoglobinA1c tests, separated by at least 3 months, should be performed sometime each year.
There are five (5) headings for Diabetes.
|2) First Hemoglobin A1c|
|3) Second Hemoglobin A1c|
|5) Urine test for protein|
Two (2) of these headings, First Hemoglobin A1c and Second Hemoglobin A1c, require both a date and a value.
SCM (Self-Care Management) requires only a date. Urine test for protein and Aspirin (Daily Aspirin Use) requires both a date and a value. If Urine test for protein and Aspirin are NA (not applicable / contra-indicated) write NA in the VALUE block. If the Urine test for protein is "Positive", indicate this by inserting a "P" (for Done & Positive) in the VALUE space.
|For Example: the provider determines JANE P DOE should not take a daily aspirin on April 17, 2003. Write NA in the Status column immediately following the Aspirin heading to indicate this finding. Under the Year 2003 column, write a 04 (April) in the month column.|
|For Example: JANE P DOE has an abnormal urine test for protein on April 17 2003. Under the Year 2003 column, write a 04 (April) in the month column. Insert a "P" and "AB" - abnormal in the VALUE space.|
There are three (3) headings for Hypertension.
|1) SCM (Self-Care Management)|
|2) First BP (First Blood Pressure)|
|3) Second BP (Second Blood Pressure)|
SCM (Self-Care Management for Hypertension)
Self-Care Management goals (top, left-hand side of form) are provided. The CAP Enrollee diagnosed with hypertension must have agreed to set one or more of these goals for the coming year. Documentary evidence of Self-Care Management may be in the form of an executed contract as shown in the example cited below or by means of evidence within the progress notes or elsewhere that a similar agreement was made.
Cardiovascular (hypertension) Self-Management http://www.healthdisparities.net/CVSelf-ManagementEngSpan.pdf Tips for Good Blood Pressure Control.
For Example: JANE P DOE's First Blood Pressure reading of 143/93 is taken on May 17, 2003. Under the Year 2003 column, write a 05 (May) in the month column and 143/93 in the VALUE column.
There are four (4) headings for Asthma.
|1) SCM Q yr. (Self-Care Management)|
|2) Action Plan|
|3) Anti-inflammatory Meds (Medications)|
|4) Peak Flow (No value is required)|
One entry per year is required for each item. The Peak Flow value is not reported.
SCM Self-Care Management goals (top, left-hand side of form) are provided. The CAP Enrollee diagnosed with asthma must have agreed to one or more of these goals for the coming year. One time each year, the documentary evidence of Self-Care Management may be in the form of an executed contract as shown in the sample cited below or evidence within the progress notes or elsewhere that Self-Care has been undertaken.
Asthma-Patient Action Plan http://www.freebreather.com/pdfs/actionPlan.pdf
The severity of asthma is assessed as follows: Mild Intermittent (MI), Mild Persistent (MP), Moderate Persistent (ModP) and Severe Persistent (SP). The appropriate abbreviation is recorded in the VALUE column.
Suggested definitions for these asthma severity assessment terms (middle of page): Multi-colored Simplified Asthma Guideline Reminder (MSAGR) Improves Asthma Outcomes. http://www.elp.ttuhsc.edu/asthma/images/2002MSAGRA.pdf
For Example: On June 25, 2003 a Severity Assessment for JANE P DOE indicates Moderate Persistent Asthma. Under the Year heading 2004, write 06 (July) in the month column. Write ModP (Moderate Persistent) in the adjacent VALUE column.
The CAP data is complete for one year for JANE P DOE.
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). In the "mth" (month) column under the heading Year 2004, write the number 06 (June). The CAP reporting requirements for Peak Flow have been met for one year.
There are two (2) headings for Depression
SCM Self-Care Management (top, left-hand side of form) goals have been provided. The CAP Enrollee diagnosed with depression must have agreed to one or more self-management goals for the coming year. The documentary evidence of Self-Care Management may be in the form of an executed contract as in the sample cited below or evidence within the progress notes or elsewhere that Self-Care has been undertaken.
Self-Management Plan Patient Handout – Process for Managing Depression
One time each year, the documentary evidence that a Depression Evaluation has been done may be in the form of the sample cited below or evidence within the progress notes or elsewhere.
Hospital Anxiety and Depression Scale (online)
For Example: JANE P DOE completes the Hospital Anxiety and Depression Scale on May 21, 2003. Under the Year 2003 heading, write a 05 (May) in the month column. 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 have completed the Target Data reporting requirements for CAP. The next step is to transfer this data to the Data Sheet scan form.