Patient Navigation Data Entry Form to Screen Crosswalk

Patient Navigation Data Entry – Form to Screen Crosswalk Outreach Navigation Intake Form / MBCIS Patient Navigation Client Intake Description Form MBCIS Screen Date of 1st contact with client or date client verbally acknowledges service provisions Encounter #1 Date First Encounter Date

The form taken of 1st encounter Type of Encounter Encounter Type If client is enrolled or enrolling in the Medicaid Treatment Act (do not use Outreach Navigation BCCCNP MTA Client? Intake Form, see Outreach Navigation MTA If Yes, Fill out Contact Information then go to MTA Client Encounter Form) N/A Enrollment Tab MBCIS – system generated once this screen is submitted Client Identifier N/A (saved) Client Last Name Last Name Last Name Client First Name First First Name Client Middle Initial M.I. M.I. Client Date of Birth Birth Date Birth Date Client Age N/A Age – system generated, no data entry Client Email Email Email Address (will appear in all caps) Street Address of residence Street Address Street Apt number Apt Apt City of residence City City If unknown, use your agency’s county County County State of residence State State If unknown, use your agency’s zip code Zip Code Zip Code Primary phone number Phone Number Phone 1 Type of phone number (type of phone) Type Secondary phone number Phone Number Phone 2 Type of phone number (type of phone) Type Number of people in household supported by yearly income # of people in the household Members Yearly income Household Yearly Income Income Client Verbal Acknowledgement for Services Obtained Client Verbal Acknowledgement Are you Hispanic or Latino? Hispanic Ethnicity Ethnicity Race (list of racial categories)

Outreach Navigation Intake Form (bottom half of form: Client Assessment and Barriers Assessed) / MBCIS Patient Navigation Client Assessment Screen Description Form MBCIS Screen Most recent screening information prior to navigation services, if known Screening Services Received Screening Services Received (Prior to Navigation) Previous Mammogram date (MM/DD/YYYY) if day is unknown, use 01 Mammogram Date Mammogram Date Previous Mammogram Result - Normal, Abnormal, Unknown Result Result Previous Pap date (MM/DD/YYYY) if day is unknown, use 01 Pap Date Pap Date Previous Pap Result - Normal, Abnormal, Unknown Result Result Check type of screening test(s) that require navigation services Screening Services Needed Screening Services Needed Check type of breast diagnostic test(s) that require navigation services Breast Diagnostic Services Needed Breast Diagnostic Services Needed Check type of cervical diagnostic test(s) that require navigation services Cervical Diagnostic Services Needed Cervical Diagnostic Services Needed Check all that apply of barriers to obtaining service that will be addressed by navigation System Barriers System Barriers Check all that apply of barriers to obtaining service that will be addressed by navigation Financial Barriers Financial Barriers Check all that apply of barriers to obtaining service that will be addressed by navigation Psychosocial Barriers Psychosocial Barriers Check all that apply of barriers to obtaining service that will be addressed by navigation Communication Barriers Communication Barriers Date navigator will next contact client Next Encounter Date Next Planned Encounter Date Type of encounter for next contact Type of Encounter Type of Encounter If client is eligible for caseload services check this box and client information will transfer, navigation services end Referred to BCCCNP Referred to BCCCNP Caseload Services Document any additional information Comments Additional Comments Person in charge of client’s navigation services Navigator Name Navigator Name Date navigator signed form Date Signed Date

Outreach Navigation Encounter Summary Form (Top Half)/ MBCIS Patient Navigation Follow-up Encounters Screen (Top Half) Description Form MBCIS Screen Date of any encounter beyond 1st encounter Follow-up Encounter Date Encounter Date Form that the encounter took Type of Encounter Encounter Type Navigation Screening Services Screening Services Completed Screening Services Completed Navigation Mammogram Date Mammogram Date Mammogram Date of Service Navigation Pap Date Pap Date Pap Date of Service Navigation Breast Diagnostic Services Breast Diagnostic Services Completed Breast Diagnostic Services Completed Navigation diagnostic mammogram done Diagnostic Mammogram Diagnostic Mammogram Navigation diagnostic mammogram date Diagnostic Mammogram Date of Service Diagnostic Mammogram Date of Service Navigation ultrasound done Ultrasound Ultrasound Navigation ultrasound date Ultrasound Date of Service Ultrasound Date of Service Navigation MRI done MRI MRI Navigation MRI date MRI Date of Service MRI Date of Service Navigation breast consult done Breast Consult Breast Consult Navigation breast consult date Breast Consult Date of Service Breast Consult Date of Service Navigation biopsy done Biopsy Biopsy Navigation biopsy date Biopsy Date of Service Biopsy Date of Service Navigation other breast diagnostic done Other (Description) Other (Description) Navigation other breast diagnostic date Other Date of Service Other Date of Service

Outreach Navigation Encounter Summary Form / MBCIS Patient Navigation Follow-up Encounters Screen Description Form MBCIS Screen Navigation Cervical Diagnostic Services Cervical Diagnostic Services Completed Cervical Diagnostic Services Completed Navigation cervical consult done Cervical Consult Cervical Consult Navigation cervical consult date Cervical Consult Date of Service Cervical Consult Date of Service Navigation colposcopy done Colposcopy Colposcopy Navigation colposcopy date Colposcopy Date of Service Colposcopy Date of Service Navigation biopsy done Biopsy Biopsy Navigation biopsy date Biopsy Date of Service Biopsy Date of Service Navigation ECC done ECC ECC Navigation ECC date ECC Date of Service ECC Date of Service Navigation diagnostic LEEP / Cone done Diagnostic LEEP / Cone Diagnostic LEEP / Cone Navigation diagnostic LEEP / Cone date Diagnostic LEEP / Cone Date of Service Diagnostic LEEP / Cone Date of Service Navigation other cervical diagnostic done Other (diagnostic test) Other (diagnostic test) Navigation other cervical diagnostic date Other Date of Service Other Date of Service Type of cancer diagnosed Cancer Diagnosis Cancer Diagnosis Status of Treatment Treatment Status Treatment Status Date Treatment Started Treatment Start Date Treatment Date Date referred to the BCCNS Navigation Consultant Referrals BCCNS Navigation Consultant Referrals BCCNS Date Date referred to ACS services Referrals ACS Referrals ACS Date Description of referral to other community services Referrals Other (description) Referrals Other (description) Date client referred to other community services Referrals Other Date Referrals Other Date [Is it necessary to contact client again? No] status = Complete, Lost to Follow-up, Refused – fill out completion date.

[Is it necessary to contact client again? Yes] Status = Follow-up needed – fill out next encounter date Outreach Navigation Status Navigation Status Only if status = Complete, lost to follow-up or refused Navigation Completed Date Completion Date Only if status = follow-up needed Next Encounter Date Next Encounter Date Document methods used to resolve client barriers Navigation Services/Referrals Provided to Resolve Navigation Services/Referrals Provided to Resolve Barriers (with to care Barriers (with comments) comments) Document any additional information Additional Comments Additional Comments Person in charge of client’s navigation services Navigator Name Navigator Name Date navigator signed form Date Signed Date

Outreach Navigation MTA Encounter Form (Bottom Half)/ MBCIS Patient Navigation MAT Client Enrollment Screen Description Form MBCIS Screen Client Enrollment Information Top Half of Form Enter on Patient Navigation Client Intake Screen Type of first encounter (check one) New Enrollment New Enrollment Type of first encounter (check one) Re-Enrollment / Renewal Re-Enrollment / Renewal Date client signed MTA application Date Application Signed MTA Signed Date Type of second encounter (check one) Follow-up Encounter (check box) Follow-up Encounter (check box) If follow-up encounter checked, enter date here Follow-up Encounter Date Follow-up Encounter Date Type of second encounter (check one) MTA Discontinued (check box) MTA Discontinued (check box) If MTA discontinued checked, enter date here MTA Discontinued Date MTA Discontinued Date Document any additional information Comments Additional Comments Person in charge of client’s navigation services Navigator Name Navigator Name Date navigator signed form Date Signed Date