Lead QI Wave 1: Data Collection Tool Lead Prevention - Data Collection Practice Name * Rainbow Babies and Children's Hospital Cleveland Clinic- Main Campus Cleveland Clinic- Stephanie Tubbs Jones Cleveland Clinic- Westown Cleveland Clinic- Independence Dayton Children's Hospital The MetroHealth System PrimaryOne Health Pediatricenter Other Practice Name Provider Name: * Data Cycle Baseline (Cycle 1) Cycle 2 Cycle 3 Cycle 4 Cycle 5 Sustainability Does this child live in a high risk zip code? * Yes (Enter Zip)Yes (Enter Zip) No Is this child insured by Medicaid? * Yes No Well child visit: * 6-month 12-month 24-month Caregiver at visit: * Mom Dad Grandparent OtherOther Date of Visit (MM//YY): Patient Gender: * Male Female Unknown Select which of the following items were documented as anticipatory guidance to reduce exposure to lead: Running water until cold when used for consumption Sources of lead exposure Wet mopping/dusting Advice about paint remediation Taking off shoes at the door Was there documentation ordering a lead test for this child? Yes No Select test type ordered Venous Capillary FOLLOW UP SECTION- WAIT ONE MONTH TO REVIEW THE FOLLOWING ITEMS FOR CHILDREN ATTENDING 12- or 24-MONTH WELL VISITS Was there documentation of a lead test being completed (either a note in the chart of results obtained or billing code from the lab) for this child? Yes No Select the initial test type completed: Venous Capillary How many days passed between test order and completion? The test results were: Negative for lead Positive for lead If positive for lead, the following items were documented for patient follow-up: For positive capillary tests, a confirmatory venous draw was ordered An actual blood level value Additional counseling was provided Please share any additional comments or lessons learned during this case. Submit If you are human, leave this field blank.
