Facility Site Review (FSR) and Medical Record Review (MRR) DHCS Resources
Clinic Policies for Primary Care Provider Settings
Instructions:
All participating provider(s) sites are required to establish safety, member rights and general policies and procedures for their practice. Please review all sample policies and procedures in our educational packet and customize any or all of the policies and their respective attachments you wish to adopt based on your clinic’s practice and processes. Please complete the Approval date, Approved by, Effective Date, and Revision date for each of the adopted policies. All providers and staff shall receive trainings/in-services on all clinic policies and procedures. Annual trainings/in-services are required for Blood-Borne Pathogens Exposure Control, Biohazardous Waste Management, and Infection Control/Standard/Universal Precautions. All clinic policies and evidence of training shall be kept on site or made available upon request.
FSR Provider Training 2022 — Video
SCAN Health Plan Provider Portal – Eligibility Search Guide (CIN)
If you have any questions or need help, please contact the Delegation Oversight Coordinator(s), Clinical
afrias@scanhealthplan.com
sgonzalez2@scanhealthplan.com
j.baek@scanhealthplan.com
Facility Site Review Table of Contents
Medical Records Review Table of Contents
Description
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MRR Preparation Checklist & Clinical Policies Requirement
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Format/Coordination of Care
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Medical Record Policy and Procedure
Medical Record Signature Sheet
Notice of Privacy Information and Form |
Documentation
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General Consent Form
Informed Consent Form
Advance Health Care Directive
• Advance Health Care Directive Policy and Procedures
• Advance Health Care Directive Education
• Advance Health Care Directive Form 1
• Advance Health Care Directive Form 2
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Preventive Care
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Comprehensive Health Assessment
• Pediatric Preventive Health Care Recommendation (Bright Futures/American Academy of Pediatrics)
• Pediatric Comprehensive Assessment (ages 0-20)
• Adult Preventive Health Care Schedule – USPSTF (last rev. 12.2024)
• Adult Comprehensive Assessment (ages 21-49)
• Geriatric Comprehensive Assessment (50+)
• Comprehensive Assessment (All Adults - Generic IHA and Preventive Care Screening Tool)
Risk Assessment
• Mini-Cog Tool (Geriatric)
• Risk Assessment Tool
• AAFP - Social Determinants of Health Risk Assessment
Preventive Care Screening Tools
Alcohol, Drugs, Tobacco Screening
• Alcohol, Drugs, Tobacco Approved Tools
• CRAFFT - Alcohol, Drugs, Tobacco Screening Tool
• NIDA - nmassist - Alcohol, Drugs, Tobacco Screening Tool
• TAPS Tool Parts I and II V2 - Alcohol, Drugs, Tobacco Screening Tool
Hepatitis Screening
• Hepatitis Risk Assessment Tool Form 1
• Hepatitis Risk Assessment Tool Form 2
Depression Screening
• PHQ2 - Depression Screening Tool
• PHQ9 - Depression Screening Tool
STI Screening
• Sexually Transmitted Infection Screening Tool
TB Screening
• Preventive Care - TB Screening Tool
ACIP Guidelines
• Immunization Schedule (0-18yrs)
• Immunization Schedule (Adults)
• VIS
• Vaccine Information Statements
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