Hiv Care Collaborative National Program Office Chart

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HIV Care Collaborative National Program Office Chart Review Tool
DOB
1. Review Date:
/____/____/201__ /
Gender
2. Review Site:
Race
 1. Fulton County Department of Health & Wellness
Ethnicity
 2. City of Philadelphia Dept of Public Health Ambulatory Health Services
ZIP
 3. City of Houston Department of Health and Human Services (DHHS)
 4. Harris Health
HH Size
 5. Houston Area Community Services
HH Income $
 6. Legacy Community Health Services
FPL %
 7. St. Hope Foundation
 8. Action AIDS
Insurance
HIV Risk
3. Client UCI: _____________________________________________
HIV+ Date
4. Client Case Status:  1. Open/Active  2. Closed
 9. Unknown
HIV Stage
5. Date of Referral From CTS to SL/PN: /____/____/201__ /
AIDS Date
5a. Referring Agency Name: _________________________________________
6. Date of Referral From HIV Clinic or Other Organization to SL/PN: /____/____/201__ /
6a. Referring Agency Name: _____________________________________________________________
7. HCC ACTIVITY DATES
MM/DD/YYYY
HCC Worker
MM/DD/YYYY
MCM Worker
HCC Assignment Date
MCM Transfer 1
MCM Transfer 2
Initial Intake Date
MCM Transfer 3
Consent for Services
CAREWare/CPCDMS
Supervisor Note 1
Consent
Supervisor Note 2
Assessment Date 1
Supervisor Note 3
Info Exchange Release
Supervisor Note 4
Assessment Date 2
Supervisor Note 5
Assessment Date 3
ISP Date 1
ISP Date 2
Comments:
ISP Date 3
Case Closure Date 1
Case Closure Date 2
Case Closure Date 3
8. HCC Enrollment Criteria:  1.Client newly diagnosed HIV+  2. Client previously lost to care  Client loosely engaged  9. Unk
9. Circumstances Regarding Previous Loss to Care:
10. Intake Verification:  Photo ID  Residency  HIV Seropositivity  Household Size  Household Income
Merck Foundation HCC Chart Review Form
12/05/2013
Page | 1

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