Pre/post Chart Review Medical Record

Medical Record #:

___ REDCap Patient ID #:__________ REDCap Return Code: _______________

NIPA: Pre/Post Chart Review

Instructions: Record the Medical Record Number of the patient you are reviewing in the space located in the upper corner of the review form. This form is provided to your site

for data gathering purposes prior to entry into the online REDCap system. DO NOT send any forms containing Medical Record information to the NIPA project team. Please refer

to the instructions sheet for further direction.

Section A: Patient Demographics

Gender:

Race (mark all that apply):

Ethnicity:

Insurance Type:

Male

Hispanic or Latino

Public

White

American Indian/ Alaskan Native

Female

Black/African American

Unknown/Not Noted

Not Hispanic or Latino

Private

Asian

Other (specify)________________

Unknown/ not noted

Uninsured

_____________________________

Unknown

Native Hawaiian/ Pacific Islander

Section B: Patient HPV Immunization History. Has the patient received:

st

nd

rd

HPV Vaccine – 1

Dose

HPV Vaccine – 2

Dose

HPV Vaccine – 3

Dose

Yes

Age:

Yes

Age:

Yes

Age:

No

No

No

Section C: Please fill in all Well Child Checks (WCC) and any other visit dates documented for this patient in the active month

If patient was eligible, did

Eligible for HPV

Age in

Visit Date

s/he receive HPV vaccine at

If patient was eligible and did NOT receive HPV vaccine, why?

Visit Type

years

vaccine at this visit?

this visit?

Visit 1

Well Visit

No

No

Refused/declined

Acute

Yes

Yes

Postposed/deferred

Chronic Care

Unable to obtain consent

If eligible for dose 2, is this

Nurse

Contraindication to HPV vaccine

visit ≥2 months from dose 1?

Other ______

Vaccine not available

Yes

Other: _____________________________

No

Not documented/unclear

Visit 2

Well Visit

No

No

Refused/declined

Acute

Yes

Yes

Postposed/deferred

Chronic Care

Unable to obtain consent

If eligible for dose 2, is this

Nurse

Contraindication to HPV vaccine

visit ≥2 months from dose 1?

Other ______

Vaccine not available

Yes

Other: _____________________________

No

Not documented/unclear

Visit 3

Well Visit

No

No

Refused/declined

Acute

Yes

Yes

Postposed/deferred

Chronic Care

Unable to obtain consent

If eligible for dose 2, is this

Nurse

Contraindication to HPV vaccine

visit ≥2 months from dose 1?

Other ______

Vaccine not available

Yes

Other: _____________________________

No

Not documented/unclear

Section D: Chart Notes (Any comments you have that you would like to convey to the study team)

NIPA Pre/Post Chart Review Form 8.13.15