3 Ambulatory Care Visit

Confidential
Sickle Cell Test Team 1
Page 1 of 3

Ambulatory Care Visit (2012)
Participant ID

__________________________________
((do not change this value))

OMB Number (0915-XXXX) Expiration date (XX/XX/20XX)
Public Burden Statement: An agency may not conduct or sponsor, and a person is not required to respond to, a
collection of information unless it displays a currently valid OMB control number. The OMB control number for this
project is 0915-XXXX. Public reporting burden for this collection of information is estimated to average ____ hours per
response, including the time for reviewing instructions, searching existing data sources, and completing and reviewing
the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of
information, including suggestions for reducing this burden, to HRSA Reports Clearance Officer, 5600 Fishers Lane,
Room 10-29, Rockville, Maryland, 20857.
Team site:

Team 1 - Site A
Team 1 - Site B
Team 1 - Site C
Team 1 - Site D
Team 1 - Site E

Reviewer's initials:

__________________________________

Date of chart review:

__________________________________

What visit occurred this month?

Heme

PCP

Both

Date of hematology visit:

__________________________________

Date of PCP visit:

__________________________________

Is the patient less than one year old?

Yes

No

Age in months at time of visit: (0 for under 1 month):

__________________________________
(number between 0 and 11)

Age in years at time of visit:

__________________________________
(number)

How many times was the patient seen in Day Hospital
or Infusion Center in the past 12 months?

__________________________________
(hospitalization for management of an illness
related or possibly related to sickle cell
disease)

How many times was the patient seen in the Emergency
Department during the past 12 months?

__________________________________
(hospitalization for management of an illness
related or possibly related to sickle cell
disease)

How many times was the patient admitted to the
hospital in the past 12 months for sickle cell
related illnesses?

__________________________________

Care Coordination
Does the SCD patient have a documented primary care
provider?

Yes

No

Not available

In the past 12 months, has the patient had a visit
with their PCP?

Yes

No

Not available

Does the patient have a care manager?

Yes

No

Not available

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Page 2 of 3

In the past 12 months, has the patient had evaluation
with a hematologist or sickle cell specialist?
Date of last evaluation with a hematologist or sickle
cell specialist:

Yes

No

Not available

__________________________________

Does the patient have a written transition plan?

Yes

No

Not available

In the past 12 months, did the patient have a written
individual care plan?

Yes

No

Not available

Was the care plan reviewed with the patient during
the current visit?

Yes

No

Not available

Is the patient up to date for PCV7 / PCV13
vaccination?

Yes

No

Not available

Is the patient up to date for PPV23/Pneumovax
vaccination?

Yes

No

Not available

Is the patient up to date for meningococcal (MCV4 or
MPSV4) vaccination?

Yes

No

Not available

Is the patient up to date for haemophilus influenza
(HIB) vaccination?

Yes

No

Not available

Did the patient receive a flu vaccine during the last
flu season?

Yes

No

Not available

Is the patient up to date for hepatitis B
vaccination?

Yes

No

Not available

Immunization

__________________________________
(not for data entry)

Routine Health Screening
Did the patient have depression screening in the past
12 months?
Depression screening date:
Did the patient have BP screening in the past 12
months?
BP screening date:
Did patient have ophthalmologic (dilated retinal)
exam in the past 12 months?
Ophthalmologic exam date:

Yes

No

Not available

__________________________________
Yes

No

Not available

__________________________________
Yes

No

Not available

__________________________________

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Confidential
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Transcranial Doppler Screening
Transcranial doppler screen in past 12 months?
Date of last TCD:

Yes

No

Not available

__________________________________

Did the patient have at least 1 abnormal TCD in the
past 12 months?

Yes

No

Not available

Did the patient have a repeat TCD within 2 months of
the abnormal TCD study?

Yes

No

Not available

Did the patient have 2 consecutive abnormal TCDs in
the past 12 months?

Yes

No

Not available

Yes

No

Not available

Transfusion Care
On transfusion protocol?
Start Date:
Has the patient been assessed for iron overload in
the past 12 months?
Assessment date:

__________________________________
Yes

No

Not available

__________________________________

Does the patient currently have iron overload?

Yes

No

Not available

Is the patient currently on chelation therapy?

Yes

No

Not available

Chelation therapy start date:
What medication is the patient using for chelation
therapy?

__________________________________
(leave blank if not available)
Desferoxamine (Desferal)
Deferasirox (Exjade)
Deferiprone (Ferriprox)
No meds taken

Hydroxyurea
In the past 12 months, has the patient's medical
record been reviewed to determine if they are a
potential candidate for Hydroxyurea use?
Date of last assessment:

Yes

No

Not available

__________________________________

Is patient candidate for hydroxyurea?

Yes

No

Not available

Is the patient currently on hydroxyurea?

Yes

No

Not available

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