Hiv Care Collaborative National Program Office Chart (Page 4 of 4) in pdf

Hiv Care Collaborative National Program Office Chart Page 4

13. REFERRALS MADE FOLLOWING CARE PLAN COMPLETION

Date

Agency/Service

Services Requested

14. CASE CONFERENCES IN WHICH HCC STAFF PARTICIPATED IN OBSERVATION PERIOD

Date

Agency/Service

Staff Participating & Their Titles

CASE CLOSURE

15. Was case discharged/closed case during the review period?  1. Yes

 2. No

 8. NA

16. If YES, did the client meet the criteria for case closure/discharge as defined in the HCC protocol?

 1. Yes

 2. No

 8. NA, case not closed

17. Reasons documented for closing case: (Check all that apply)

 0, 1 All goals met / no needs as defined in HCC protocol

 0, 1 Client continues no show, lack of follow-up with worker

 0, 1 Client became self sufficient

 0, 1 Death of the client

 0, 1 At the client’s or legal guardian request

 0, 1 Client actions put the agency, case manager or other clients at risk

 0, 1 Client moved out of service area

 0, 1 Client incarcerated

 0,1 Client could not be contacted using methods defined in HCC protocol

 0, 1 Client is hospitalized

 0, 1 Client refused service

 0, 1 Unknown, unclear, contradictory documentation

 0, 1 NA

Reviewer Comments

Merck Foundation HCC Chart Review Form

12/05/2013

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Hiv Care Collaborative National Program Office Chart Page 4