Colorado WIC Program Level I Certification

Participant Record Review DIRECTIONS: The supervisor (or other designated personnel) is to evaluate at least one certification or recertification visit of each of the following participant types encountered by the trainee: 1. Pregnant Woman 2. Infant 3. Child Each certification or recertification is reviewed against the established criteria as specified in the Participant Record Review checklist. Place a check () in the "PASS" column if the criteria are met, a check () in the "FAIL" column if they are partially or not met, and a check () in the "N/A” (NOT APPLICABLE) column if the question does not apply to the participant's Compass record. Place pertinent notations in the COMMENTS section. SCORING: Add up the total number of questions applicable for this particular trainee. In other words, do not include any items marked N/A. This is the total number of points or applicable responses. Then subtract the number of "FAILS" received to find the number of correct responses to the applicable questions. Now divide the correct responses by the total number of points possible and multiply by 100. This is the score in percentage terms. EXAMPLE:

Correct Responses _______________ _

x

100 = _____

%

Total Points The trainee must score 90 percent or better for a passing grade. The supervisor will review the completed record review with the trainee. The completed Participant Record Review remains in the supervisor's possession. Document completion in Compass by accessing: Operations>Staff> Staff Competency panel. NAME OF TRAINEE _____________________________________________________________________

SCORE ___________________________________________

Signature of Supervisor or Reviewer ___________________________________________________

DATE ____________________________________________ 1

P=Pregnant, I=Infant, C=Child

Category A. Family/Intake 1.

P / I / C Pass Fail N/A

P / I / C Pass Fail N/A

P / I / C Pass Fail N/A

TOTAL:

TOTAL:

TOTAL:

Comments

Additional Endorser or proxy is correctly entered in Compass.

2.

Preferred spoken language captured on Family Panel if other than English. 3. Expected DOB completed for infants and children < 24 months (Enrollment Screen on Family panel). 4. Referred to WIC completed at initial certification visit. 5.

Clinic Educator field completed if applicable.

6.

Appropriate proof of identity recorded per policy. If participant is not physically present for appointment, appropriate reason given from drop down.

7.

8.

Other program participation field completed.

9.

Contact/Address panel completed.

10. Proof of residency recorded per policy. 11. Proof of income recorded per policy. 12. Proper use of Affidavit for No Proof of income. 13. Adjunctive eligibility correctly documented. Grand TOTAL:

2

P=Pregnant, I=Infant, C=Child

Category B. Assessment 1.

Pass

P / I / C Fail N/A

TOTAL:

TOTAL:

P / I / C Pass Fail N/A

Comments

Women For pregnant women, pregnancy panel is completed appropriately (pre-pregnancy weight recorded, EDD updated, etc.).

2.

Height and weight recorded at certification/recertification visits.

3.

Prenatal weight recorded at least once per trimester for all clinic visits. (Education Choice may be offered one time after the cert/recert visit, allowing one measurement to be excused.)

4.

Weight gain risk factors assigned appropriately if applicable (NRF 131, 133).

5.

Hemoglobin test done (if required).

6.

Completed a thorough Nutrition Interview a. Health Care Provider field completed per policy. b. Bolded questions are answered for data reporting (certification and recertification appointments). c. Radio buttons have been completed. d. Sufficient information is captured in the Note boxes to explain associated risk factors. e. Breastfeeding information is captured at each prenatal visit. All appropriate risk factors have been assigned on the Risk panel based on data gathered in the Anthropometric panel, Blood panel and Nutrition Interview.

7.

P / I / C Pass Fail N/A

TOTAL:

Grand TOTAL:

Additional Comments: 3

P=Pregnant, I=Infant, C=Child

Category Assessment Continued Infant/Child 1. Infant added to pregnancy record. 2.

Measurements are entered for infant/child at certification, recertification and mid-certification.

3.

Growth/weight gain risk is appropriately assigned if applicable (NRF 135).

4.

Hemoglobin test is done (if required).

5.

Completed documentation of lead screening for children at each cert and recert.

6.

Completed a thorough Nutrition Interview. Health Care Provider field completed per policy. Bolded questions are answered for data reporting certification and recertification. Radio buttons have been completed. Sufficient information is captured in the Note boxes to explain associated risk factors.

a. b.

c. d.

7.

P / I / C Pass Fail N/A

P / I / C Pass Fail N/A

P / I / C Pass Fail N/A

TOTAL:

TOTAL:

TOTAL:

Comments

All appropriate risk factors have been assigned on the Risk panel based on weight gain, blood work and Nutrition Interview.

Grand TOTAL:

4

P=Pregnant, I=Infant, C=Child

Category C. Certification/Termination 1. Signature was collected for certification. a. If signature not completed, the General Signature document is completed and scanned into Compass.

P / I / C Pass Fail N/A

P / I / C Pass Fail N/A

P / I / C Pass Fail N/A

TOTAL:

TOTAL:

TOTAL:

P / I / C Pass Fail N/A

P / I / C Pass Fail N/A

P / I / C Pass Fail N/A

Comments

Grand TOTAL:

Additional Comments:

P=Pregnant, I=Infant, C=Child

Category D. Education and Care 1.

2. 3. 4.

5.

6. 7.

8.

Comments

Nutrition Education Panel completed to record required nutrition education contact. Participant comments/concerns recorded in the care plan. Assessment is accurate/appropriate. a. Addressed weight gain/growth/blood. Adequate documentation is provided in care plan to support assignment of nutrition practice NRFs. Counseling: a. Related to NRFs and/or participant’s concerns. b. Focused on 1-2 issues to top priority. Pamphlets provided are appropriate and related to counseling topics. Behavior change goal: a. Specific. b. Appropriate. c. Relates to NRFs/counseling provided. Referrals are appropriate and relate to participant concerns and/or counseling points. 5

9. High risk referred/scheduled with the high risk counselor at the appointment the High Risk NRF was identified. TOTAL:

TOTAL:

TOTAL:

P / I / C Pass Fail N/A

P / I / C Pass Fail N/A

P / I / C Pass Fail N/A

TOTAL:

TOTAL:

TOTAL:

P / I / C Pass Fail N/A

P / I / C Pass Fail N/A

P / I / C Pass Fail N/A

Grand TOTAL:

Additional Comments:

P=Pregnant, I=Infant, C=Child

Category

Comments

High Risk Participants: 1. 2.

3.

Nutrition Education panel completed and noted as a High Risk follow-up. High risk participant received high risk counseling by high risk counselor within appropriate time frame. Compass care plan completed by high risk counselor and counseling/follow-up are appropriate. Grand TOTAL:

Additional Comments:

P=Pregnant, I=Infant, C=Child

Category E. Food Issuance and Scheduling Foods 1. 2.

Comments

Assigns/tailors food package to meet the participant’s needs. For Special Diets: a. Physician Authorization Form is complete and contains high risk 6

3.

4.

counselor signature and the PAF has been scanned into Compass. b. Documentation link is complete and appropriate. Correct number of food benefits are issued: a. Up to 3 months for low risk participants. b. 1 month for high risk participants (except children with NRF 113 may be issued 3 months). Signature collected for food benefits a. If signature was not captured on signature pad, the General Signature Document was completed and scanned into Compass (exception: Remote Benefit Issuance).

P=Pregnant, I=Infant, C=Child

Category F. Scheduler 1. Gives participant an appropriate return appointment according to the type of appointment needed, length of time and date to prevent proration of food benefits (if applicable).

TOTAL:

TOTAL:

TOTAL:

P / I / C Pass Fail N/A

P / I / C Pass Fail N/A

P / I / C Pass Fail N/A

TOTAL:

TOTAL:

TOTAL:

Grand TOTAL: Comments

Grand TOTAL:

Additional Comments:

7