TALK – Adolescent Well Visit Chart Review Tool TALK - Adolescent Well Visit Chart Review Tool - V2 Practice Name * Name of person submitting data * Date * Birthdate: * Age: * Gender: * Female Male Caregiver Attending Visit: Mom Dad Guardian/Grandparent/Other None Well Child Visit (WCV): * 11 y.o. 12 y.o. 13 y.o. 14 y.o. 15 y.o. 16 y.o. 17 y.o. 18 y.o. 19 y.o. 20 y.o. 21 y.o. Recommended AAP Bright Futures Screening 1. Was a psychosocial asessment(s) completed using: * HEEADSSS comprehensive assessment? Depression screening? Substance use/abuse screening? None of the above were used What specific screening tool(s) was used for Depression? * PHQ-2 PHQ-9 OtherOther What specific screening tool(s) was used for Substance Use? * CRAFFT OtherOther Anticipatory Guidance/Counseling/Screening 2. Was the following anticipatory guidance documented: * Reproductive Health? Mental Health? Healthy nutrition and physical activity? Injury and violence prevention? Substance use/abuse? No Anticipatory Guidance documented The TALK AIM focuses on Reproductive Health: If done, which specific reproductive health topic(s) were documented? * Pregnancy prevention/contraception STD prevention STD screening if sexually active None OtherOther 3. Regarding STD Screening, was there documentation that the patient was: Sexually Active? * No - move to measure 4 Yes - continue to 3b 3b. Annual Chlamydia screening was recommended and ordered/completed? * No Yes, but patient declined Yes, ordered or completed Patient was not due yet Immunization 4. Regarding the HPV vaccine: please list the dates of all HPV vaccines given (including current visit if applicable): Date of First HPV Vaccine Date of Second HPV Vaccine Date of Second HPV Vaccine Date of Third HPV Vaccine Date of Third HPV Vaccine Did the patient receive the HPV vaccine today? * Yes No If no, please note why: * N/A - Patient not due for HPV vaccine (less than 1-2 months between 1st and 2nd dose, less than 4 months between 2nd and 3rd dose or series complete. It was recommended, but the patient/family refused/postponed. Reason given:It was recommended, but the patient/family refused/postponed. Reason given: Provider postponed to later date. Reason given:Provider postponed to later date. Reason given: Contraindication to HPV vaccine Other:Other: There was no documentation about why it was not received today. If you are human, leave this field blank.
