Form 2 Medical Record Data Abstraction Screenshots

Provider Site Screening Interview Form

Date of screening call	RS Name
Facility Name	Location (City, State)
Participants (full name & credentials)	Title and Role

Clinic Characteristics

Geographic location:

• Rural

• Urban

• Suburban

Model of care:

• Exclusively primary care: Primary care provider is the lead provider for care of the patient’s HIV in providing most primary care and most HIV-related care; no specialist physician (HIV specialist or Infectious Disease (ID) physicians) provides any HIV care.

• Primary care-dominant, co-management: Primary care provider provides majority of HIV-related care, and a specialist physician provides some HIV care (on or off-site).

• Specialist-dominant, co-management: HIV specialist provides majority of HIV-related care, and a primary care provider provides some primary care (on or off-site).

• Exclusively HIV specialist care: A HIV specialist provides all HIV-related care and primary care (non HIV care).

Health Records

1. 

   If EHR, go to 2

   If paper-based, skip to 5

   Which of the following does your facility use?

   1. electronic health record (EHR)

   2. paper-based medical records

2. Which EHR system does your facility use?

3. When did your facility start to use an EHR? (year)

4. How long has your facility been using the current EHR?

5. 

   If No – skip to CLOSING

   Would our team be able to view your EHR medical records on site to conduct chart abstractions?

   1. Yes

   2. No

6. 

   If b or c – skip to CLOSING

   Where are paper-based medical records located?

   1. 

      SKIP to 7, if facility has EHR

      Facility (easy-access)

   2. Warehouse

   3. Other [Specify]:

7. What other forms of records system does your facility use? [check all that apply]

• Case management

• Mental health system

• CAREWare

• Other [Specify]:

8. Can your facility accommodate space for two record abstractors for 4 days?

   1. 

      If No – skip to CLOSING

      Yes

   2. No

9. Is there a person that could walk us through your facility systems while our team is on site to navigate your clinic chart system?

   1. 

      If yes, go to 8.1

      If No, skip to CLOSING

      Yes

   2. No

8.1 IF YES: What is her/his name?

10. 

    If yes, skip to 10 If No, go to 9.1

    Can your facility provide access to two computers for our team to access the patients’ health record?

    1. Yes

    2. No

9.1 IF NO: Can your facility provide access to at least one computer for our team to do the chart abstraction?

1. 

   If No – skip to CLOSING

   Yes

2. No

11. Can your facility provide secure WIFI access to our staff while we are on site?

    1. Yes

    2. 

       If no, add note to tracker that mobile hot-spot will be needed

       No

Approvals and Logistics

12. What types of approvals are required by your facility for us to collect client data? [check all that apply]

• IRB approval

• Signed confidentiality agreement

• 

  Note required approval on tracker and let assigned team know for follow-up

  Data use agreement

• Memorandum of understanding (MOU)

• Business associate agreement (BAA),

• Confidentiality agreement

13. 

    Note time-frame for required approval on tracker and let assigned team know for follow-up

    Approximately how long does it take to receive approval for each item (Q11) from your facility?

If site meets the criteria:

Based on your answers, your site meets the criteria for this Ryan White HIV/AIDS Program study. We are looking at conducting site visits between [X date and Y date]. Could you give me three weeks that would work for your facility for a site visit?

Our next step is to match your site with a team of two abstractors. In addition, I would like to set up a time to conduct a pre-site visit phone interview with you. Can you give me three timeframe options that would work for you for a 60 minute call?

Public reporting burden for his collection of information is estimated to average 0.5 hours per response, including the time for reviewing instructions, searching existing data sources, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to HRSA Reports Clearance Officer, 5600 Fishers Lane, Room 14N136B, Rockville, Maryland, 20857.

OMB No. 0906 – xxxx Expiration Date XX/XX/20XX

OMB No. 0906 – xxxx Expiration Date XX/XX/20XX

OMB No. 0906 – xxxx Expiration Date XX/XX/20XX