e h r review toolfor c p s p（e h r审查系统c p s p）（6页）.docVIP

EHR Review Tool for the Comprehensive Perinatal Services Program (CPSP) Date: ___________ Conducted by: ________________________________________ Name of EHR template: ___________________ Section 1: CPSP Program Requirements Element Yes No Source Comments Review Process for CPSP EHR Template The PSC reviews the EHR content and functionality using approved guidelines to assure that the system includes all required elements. If the system does not meet a requirement, the provider must identify an alternative documentation process. (1) §51249 (4) p 72 EHR Functionality Basics Requirements as listed in Title 22, California Code of Regulations, HS Code and WI Code, and CPSP Policies CPSP Client Orientation Includes the seven required elements. What services will be provided §51348.1 (i) Who will provide the services §51348.1 (i) Where to obtain the services §51348.1 (i) When the services will be delivered §51348.1 (i) Procedures to follow in case of an emergency §51348.1 (i) Patient rights §51348.2 (c) Participation is voluntary §51348.2 (a) Initial Client Orientation must be provided before any other CPSP services in order to ensure patient’s agreement to participate in the program. (1) §51348.2. Patient Rights Additional Client Orientation may be billed throughout the pregnancy and postpartum. (3) Obstetric Requirements Prenatal Medical Record incorporates the most recent edition of the American College of Obstetricians and Gynecologists (ACOG) guidelines (information item; provider is responsible to assure). (8) p. 1-8 (8) p 2-9 Medical staff, when working in the OB template, can view the CPSP ICP. Assessments All seven pregnancy weight gain grids (2009 Institute of Medicine) are present and function appropriately as demonstrated , which includes plotting the weight at each visit as recorded. (9) p NUTR-10 Allows the three assessments (psychosocial, health education and