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TAV Service Note Review Summation ‐ MH ‐ Care Coordination Agency: Reviewer: NO SERVICES THIS PERIOD Record 1 1) County of service yes no 7) Dental appt. summary 2) yes no 8) Referrals, outcomes, & 3) yes no plan for follow up 4) yes no 9) Client family feedback 5) Service provider 6) Location Concerns & issues Staff response Medical appt. summary yes no MH Oral Health Survey Agency comments Pass? IDPH yes no comments Record 2 Agency comments Pass? IDPH yes no comments Period Reviewed: Service Date: TAV Contact ID#: Service Date: TAV Contact ID#: August 8, 2017 10) yes no yes no yes no yes no yes no 1) County of service yes no 7) 2) yes no 8) 3) yes no 4) yes no 9) 5) 6) Location Concerns & issues Staff response Medical appt. summary yes no Dental appt. summary Referrals, outcomes, & plan for follow up Client family feedback Service provider MH Oral Health Survey 10) yes no yes no yes no yes no yes no

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Page 1: TAV Service Note Review Summation MH Care Coordination ... · 10) MH Oral Health Survey yes no yes no yes no yes no yes no 1) County of service yes no 2) yes no 7) 8) 3) yes no 4)

TAV Service Note Review Summation ‐ MH ‐ Care Coordination

Agency: Reviewer: NO SERVICES THIS PERIOD

Record 1

1) County of service yes no

7)

Dental appt. summary

2) yes no

8)

Referrals, outcomes, &

3) yes noplan for follow up

4) yes no9)

Client family feedback

5)

Service provider

6)

Location

Concerns & issues

Staff response

Medical appt. summary yes no MH Oral Health Survey

Agency

comments

Pass? IDPH      yes 

     no comments

Record 2

Agency

comments

Pass? IDPH      yes 

     no comments

Period Reviewed: 

Service Date:

TAV Contact ID#: Service Date:

TAV Contact ID#:

August 8, 2017

10)

yes no

yes no

yes no

yes no

yes no

1) County of service yes no

7)2) yes no

8)3) yes no

4) yes no9)

5)

6)

Location

Concerns & issues

Staff response

Medical appt. summary yes no

Dental appt. summary

Referrals, outcomes, &

plan for follow up

Client family feedback

Service provider

MH Oral Health Survey10)

yes no

yes no

yes no

yes no

yes no

Page 2: TAV Service Note Review Summation MH Care Coordination ... · 10) MH Oral Health Survey yes no yes no yes no yes no yes no 1) County of service yes no 2) yes no 7) 8) 3) yes no 4)

TAV Service Note Review Summation ‐ MH ‐ Care Coordination

Agency: Reviewer:

Record 3

Agency

comments

Pass? IDPH      yes 

     no comments

Record 4

Agency

comments

Pass? IDPH      yes 

     no comments

TAV Contact ID#: Service Date:

Period Reviewed: 

TAV Contact ID#: Service Date:

August 8, 2017

1) County of service yes no

7)2) yes no

8)3) yes no

4) yes no9)

5)

6)

Location

Concerns & issues

Staff response

Medical appt. summary yes no

Dental appt. summary

Referrals, outcomes, &

plan for follow up

Client family feedback

Service provider

MH Oral Health Survey10)

yes no

yes no

yes no

yes no

yes no

1) County of service yes no

7)2) yes no

8)3) yes no

4) yes no9)

5)

6)

Location

Concerns & issues

Staff response

Medical appt. summary yes no

Dental appt. summary

Referrals, outcomes, &

plan for follow up

Client family feedback

Service provider

MH Oral Health Survey10)

yes no

yes no

yes no

yes no

yes no

Page 3: TAV Service Note Review Summation MH Care Coordination ... · 10) MH Oral Health Survey yes no yes no yes no yes no yes no 1) County of service yes no 2) yes no 7) 8) 3) yes no 4)

TAV Service Note Review Summation ‐ MH ‐ Care Coordination

Agency: Reviewer:

Record 5

Agency

comments

Pass? IDPH      yes 

     no comments

Record 6

Agency

comments

Pass? IDPH      yes 

     no 

comments

TAV Contact ID#: Service Date:

Period Reviewed: 

TAV Contact ID#: Service Date:

August 8, 2017

1) County of service yes no

7)2) yes no

8)3) yes no

4) yes no9)

5)

6)

Location

Concerns & issues

Staff response

Medical appt. summary yes no

Dental appt. summary

Referrals, outcomes, &

plan for follow up

Client family feedback

Service provider

MH Oral Health Survey10)

yes no

yes no

yes no

yes no

yes no

1) County of service yes no

7)2) yes no

8)3) yes no

4) yes no9)

5)

6)

Location

Concerns & issues

Staff response

Medical appt. summary yes no

Dental appt. summary

Referrals, outcomes, &

plan for follow up

Client family feedback

Service provider

MH Oral Health Survey10)

yes no

yes no

yes no

yes no

yes no

Page 4: TAV Service Note Review Summation MH Care Coordination ... · 10) MH Oral Health Survey yes no yes no yes no yes no yes no 1) County of service yes no 2) yes no 7) 8) 3) yes no 4)

TAV Service Note Review Summation ‐ MH ‐ Care Coordination

Agency: Reviewer:

Record 7

Agency

comments

Pass? IDPH      yes 

     no 

comments

Record 8

Agency

comments

Pass? IDPH      yes 

     no 

comments

Service Date:

Service Date:TAV Contact ID#:

Period Reviewed: 

TAV Contact ID#:

August 8, 2017

1) County of service yes no

7)2) yes no

8)3) yes no

4) yes no9)

5)

6)

Location

Concerns & issues

Staff response

Medical appt. summary yes no

Dental appt. summary

Referrals, outcomes, &

plan for follow up

Client family feedback

Service provider

MH Oral Health Survey10)

yes no

yes no

yes no

yes no

yes no

1) County of service yes no

7)2) yes no

8)3) yes no

4) yes no9)

5)

6)

Location

Concerns & issues

Staff response

Medical appt. summary yes no

Dental appt. summary

Referrals, outcomes, &

plan for follow up

Client family feedback

Service provider

MH Oral Health Survey10)

yes no

yes no

yes no

yes no

yes no

Page 5: TAV Service Note Review Summation MH Care Coordination ... · 10) MH Oral Health Survey yes no yes no yes no yes no yes no 1) County of service yes no 2) yes no 7) 8) 3) yes no 4)

TAV Service Note Review Summation ‐ MH ‐ Care Coordination

Agency: Reviewer:

Record 9

Agency

comments

Pass? IDPH      yes 

     no 

comments

Record 10

Agency

comments

Pass? IDPH      yes 

     no 

comments

Period Reviewed: 

TAV Contact ID#: Service Date:

TAV Contact ID#: Service Date:

August 8, 2017

1) County of service yes no

7)2) yes no

8)3) yes no

4) yes no9)

5)

6)

Location

Concerns & issues

Staff response

Medical appt. summary yes no

Dental appt. summary

Referrals, outcomes, &

plan for follow up

Client family feedback

Service provider

MH Oral Health Survey10)

yes no

yes no

yes no

yes no

yes no

1) County of service yes no

7)2) yes no

8)3) yes no

4) yes no9)

5)

6)

Location

Concerns & issues

Staff response

Medical appt. summary yes no

Dental appt. summary

Referrals, outcomes, &

plan for follow up

Client family feedback

Service provider

MH Oral Health Survey10)

yes no

yes no

yes no

yes no

yes no

Page 6: TAV Service Note Review Summation MH Care Coordination ... · 10) MH Oral Health Survey yes no yes no yes no yes no yes no 1) County of service yes no 2) yes no 7) 8) 3) yes no 4)

TAV Service Note Review Summation ‐ MH ‐ Care Coordination

Agency: Reviewer:

IDPH Overall Comments

Total Passed:

Total Reviewed:

Period Reviewed: 

August 8, 2017

______

______


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