Form 4 Forms_20110919.v1

Patient Navigator Outreach and Chronic Disease Prevention Program

Local Identifiers (site use only)

Navigator Encounter Form
Study Data

Tasks

At least one must be checked

Study ID:
Navigator ID:
Encounter Date:
Method

Check one

 Telephone
 No contact
 Home Visit
 Other face-to-face (not home visit)
Setting, optional:
 Written
 Group session
 Other
Specify, optional:
Person
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Check all that apply

Patient
Social network (family/friends)
Healthcare staff/provider
Social services/community org rep
Other
Specify:

Other (optional)

Topic addressed:
Reason for encounter:

Minutes:
Rev. 19-Sep-2011

Check all that apply

 Identify or address barrier
 Coordinate health care appt logistics
(patient w/disease only)
 Discuss diagnosed disease and
its treatment
 Coordinate education & services for
preventive care/early detection
 Coordinate health care coverage
 Assist with filling Rx or medical
equipment request
 Coordinate social services
 Link to community organization
 Clinical trials notification
 Confirm patient status/maintain
relationship
 Education re: life skills/selfmanagement
Additional notes (optional)

Barriers

Check all that apply

 No barriers identified/addressed
System/Access
 No established primary care
 Transportation (local)
 Location of health care (non-local)
 Housing during treatment
 System problems with scheduling care
 System problems with coordinating care
 Lack of access to a specialist
 System culture and practices
 Staff beliefs and attitudes
 Difficult access to appropriate food
Personal
 Disability/comorbidity
 Unable to care for self at home
 Costs: health care
 Costs: medication/equipment
 Employment issues
 Internal psychological (anxiety)
 Habitual unhealthy lifestyle
 External psychosocial (isolated)
 Health literacy/lack of information
 Language
 Cultural/personal beliefs and attitudes
 Lack of reliable communication
Family
 Childcare/family care issues
 Housing
Other
 Other 1
Specify:
 Other 2
Specify:
Entered by:

Date:

Navigator Encounter Form (page 2)

Study ID

Notes (local use only)

Updates to Navigated Condition
Navigated Condition
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Updates to Coverage (optional)
Pharmacy Assistance Check one

Rev. 19-Sep-2011

Date:

Cancer-related conditions

Check one

Asthma, at risk/pre-asthma
Asthma, diagnosed
CHF, diagnosed
CVD, at risk/family history
CVD, diagnosed
Depression, positive screen
Depression, diagnosed
Diabetes, at risk/family history
Diabetes, pre-diabetes
Diabetes, diagnosed
Gestational diabetes
Hyperlipidemia
Hypertension, positive screen
Hypertension, diagnosed
Obesity (adult)
Obesity (pediatric)
Other:
Cancer, screening
Cancer, abnormal finding
Cancer, diagnosis

 No
 Yes
 Not Available

Entered by:

Type of cancer:
Stage:

0

1

2

3

4

N/A

Optional Information:
Substage:

A

B

C

TNM Staging:

Histology:

Date Associated with New Condition
__ __ / __ __ / __ __ __ __

Entered by:

HC Coverage
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Date:
Check all that apply

No coverage
Medicare
Medicaid
IHS
Private insurance
Other Government plan
Single service plan
Reduced-fee/sliding scale
Free care
Other
Specify:

Patient Navigator Outreach and Chronic Disease Prevention Program

Local Identifiers (site use only)

Navigator Characteristics
Details

Language

Gender:  Male
 Female
 Transgender

Primary Language:
(See list below for options)

Birth year:

Additional Languages (Check all that apply)
 None
 English
 Spanish
 Chinese
 Fijian
 Filipino: Ilocano
 Filipino: Tagalog
 Filipino: Visayan
 Filipino: Other
 French
 Haitian Creole
 Hmong
 Japanese
 Korean
 Micronesian: Chuukese
 Micronesian: Kosraean
 Micronesian: Marshalese
 Micronesian: Pohnpeian
 Micronesian: Yapese
 Mixteco
 Navajo
 Samoan
 Somali
 Tongan
 Vietnamese
 Other
Specify:

Ethnicity:  Hispanic or Latino
 Non-Hispanic

3-digit zip prefix:
Hired on:
Education

Check one

No formal education
Primary education only
Some HS/secondary education
HS Diploma/GED/other secondary
education
 Some college/vocational school/other
post-secondary education
 Completed college, post-secondary or
vocational school
 Post-college/graduate school
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Race
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Check all that apply

White
Black/African American
Asian
Native Hawaiian/Pacific Islander
American Indian/Alaskan Native

Optional race coding:

Rev. 19-Sep-2011

Professional Training Check all that apply

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None
RN
LPN
Medical Assistant/ Nurses Aide
Social Worker
Phlebotomist
Radiology Technologist
Mammography Technologist
PN certification
Community Health Worker (CHW)
certification
CHW training for specific condition
Workshops/trainings
Certified Medical Interpreter
Alternative Health Care Provider
Other
Specify:

Study Data
Navigator ID:
Entered by:

Date:

Patient Navigator Outreach and Chronic Disease Prevention Program

Local Identifiers (site use only)

Clinical Measures/Lab Form
Study Data
Study ID:

Test Type

NR*

Test/Rx/Visit
Date

 No medical record

Reporting Requirements by Navigated Condition

Result(s)

Asthma, at risk/pre-asthma:
Current smoker
Asthma, diagnosed:
Peak Flow, ER/Hospitalization, Albuterol Prescription Date,
Current smoker

 Fasting blood glucose

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 HbA1c

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 Dilated eye check

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 Diabetic foot check

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CVD, at risk/family history:
Current smoker

 Diabetes self-management plan

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CVD, diagnosed:
Blood Pressure, ER/Hospitalization, Lipids, Current smoker

 Blood pressure

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 Antihypertensive prescription date

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 Peak flow

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 ER/Hospitalization
(record all dates; use back if needed)

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 Albuterol prescription date

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 Lipids

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 Statin prescription date

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 BMI

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 Diuretic prescription date

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 Current Smoker

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 Other, Specify:



CHF, diagnosed:
ER/Hospitalization, Diuretic Prescription, Current smoker

Systolic:

Depression, positive screen or diagnosed:
Current smoker
Diabetes, at risk/family history, pre-diabetes, or
gestational diabetes:
Current smoker; Fasting Blood Glucose or HbA1c
Diabetes, diagnosed:
HbA1c, Dilated Eye Check, Diabetic Foot Check, Diabetes
Self-management Plan, Blood Pressure, ER/Hospitalization,
Lipids, BMI, Current smoker

HDL:

LDL:

Hyperlipidemia, diagnosed:
ER/Hospitalization, Lipids, Statin prescription date, Current
smoker
Hypertension, positive screen:
Blood Pressure, Current smoker
Hypertension, diagnosed:
Blood Pressure, Antihypertensive Prescription Date,
ER/Hospitalization, Lipids, Current smoker

 Yes

 No

Obesity, adult or pediatric:
BMI, Current smoker
Cancer, screening, abnormal finding, or diagnosed:
Current smoker

* Not recorded in medical record

Rev. 19-Sep-2011

Diastolic:

Entered by:

Date:

Patient Navigator Outreach and Chronic Disease Prevention Program

Local Identifiers (site use only)

Co-Occurring Disorders
Study Data

Study ID:
Abstraction Date:

List all chronic, co-occurring disorders present for patient at the time of chart review.
Data must be from medical records, not self-reported.
No Medical Record
No Co-Occurring Disorders
Description

Rev. 19-Sep-2011

Notes (local use only)

Entered by:

Date:

Patient Navigator Outreach and Chronic Disease Prevention Program

Local Identifiers (site use only)

Update to Navigation Status

Study Data
Study ID:
Navigator ID:

Status
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Check one

In Progress*
Inactive*
Withdrew
Lost
Ineligible
Died
Complete
End of grant (in progress)
End of grant (stable, not complete)

Date (date navigation status changed):
__ __ / __ __ / __ __ __ __

Reason for change in navigation status
(optional):

Closeout only:
Pharmacy Assistance Check one
 No
 Yes
 Not Available
HC Coverage
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Check all that apply

No coverage
Medicare
Medicaid
IHS
Private insurance
Other Government plan
Single service plan
Reduced-fee/sliding scale
Free care
Other
Specify:

Other Data Due At Closeout

* Closeout data not required when moving a
patient to a status of In Progress, or
Inactive.

Rev. 19-Sep-2011

Check if complete
 VR-12
 Co-occurring disorders
 Lab

Entered by:

Date: