Form 0920-1154 Peditrician - ECHO Chart Review

Form Approved

OMB No. 0920-1154

Exp. Date 1/31/2023

AAP Neurodevelopment ECHO Chart Review

Welcome to the AAP Neurodevelopmental ECHO! We are thrilled that you are part of this program. As is typical for Quality Improvement (QI) collaboratives, you will track measures through de-identifed chart reviews to ensure that changes you are making are having a positive impact and contribute to the progress towards your improvement goals.

For de-identified data collection, review charts (n=20) for patients aged birth to 8 years who were seen at the practice the previous month as a new patient or for a well child visit. For each chart record the information below.

1.

Please identify the age of the patient at the time of the office visit (0-8 years old):

Age

Documentation of Birth History

2.

For patients who received a prenatal or newborn visit...

Did the patient have a documented birth history of maternal drug or alcohol consumption for the following:

Use of prenatal vitamins

Smoking or use of tobacco products Consumed alcohol

Use of marijuana

Use of illicit/illegal recreational drugs Use of other medications

None

NA

Public reporting burden of this collection of information is estimated to average 12 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. 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. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to - CDC/ATSDR Reports Clearance Officer; 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333 ATTN: PRA (0920-1154).

3.

For the patients who received a new patient visit for children through 8 years of age (not including newborns)...

Did the patient have a documented birth history of maternal drug or alcohol consumption for the following:

Use of prenatal vitamins

Smoking or use of tobacco products Consumed alcohol

Use of marijuana

Use of illicit/illegal recreational drugs Use of other medications

None

NA

 

Documentation of Developmental Screening

4.

For the patients through 8 years who had a well visit during the data collection period...

Did the patients have a documented developmental/behavioral screen completed?

Yes No

Documentation of Referral for Additional Assessment

5.

Did the patient have a positive screen or was a developmental delay identified?

Yes

No

6.

Was the patient referred for additional follow up with other professionals including developmental pediatric providers, clinical genetic providers, psychiatrists, psychologists?

Yes No

Documentation of Counseling

7.

Did the patient/family receive counseling regarding child and family strengths, community resources and support systems/protective factors associated with neurodevelopmental risk?

Yes No

2