MARCH 15, 2006 FORMAT Form Approved

OMB No. 0930-0269

Expiration Date 09-30-2007

Public reporting burden for this collection of information is estimated to average 20 minutes per response; including the time for reviewing 

instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of 

information. Send comments regarding this burden estimate or any other aspect of this collection of information to SAMHSA Reports Clearance 

Officer, Room 7-1045, 1 Choke Cherry Road, Rockville, MD 20857. An agency may not conduct or sponsor, and a person is not required to 

respond to a collection of information unless it displays a currently valid OMB control number. The control number for this project is 0930-0269.

DATE: |__|__| |__|__| |__|__|__|__| START TIME: |__|__| : |__|__| END TIME: |__|__| : |__|__|

MR_MO MR_DY MR_YR MR_START MR_END

MOTHER’S ID# |__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|

MR_MOM

EVALUATION PHASE: Intake |__|1 Delivery |__|2 3-months |__|3 6-months |__|4 Discharge |__|6

MR_INTERVIEW_TYPE

PERSON COMPLETING |_______________| GRANT# TI |__|__|__|__|__|

MR_INTERVIEWER MR_SITE

MEDICAL RECORD AUDIT

If information should be present and is not, check NOT PRESENT for that chart. If information or a response to the information 

is present, rate the quality of the information/response with SUPERIOR, SATISFACTORY, and UNACCEPTABLE. Check NOT 

APPLICABLE to score items that do not apply to a given chart.

Only check one response per question per chart.

WOMEN

Superior Satisfactory Unacceptable Not Present Not Applicable

MR_W01

1. Appropriate past medical history................................ 3 2 1 -9 -1

MR_W02

2. Completed history and physical ................................ 3 2 1 -9 -1

MR_W03

3. Allergies and adverse drug reactions ......................... 3 2 1 -9 -1

MR_W04

4. Diagnoses of existing health concerns ...................... 3 2 1 -9 -1

MR_W05

5. Mammograms........................................................... 3 2 1 -9 -1

MR_W06

6. Pap smear and Gyne/Pelvic ...................................... 3 2 1 -9 -1

MR_W07

7. Clinical breast exams ................................................ 3 2 1 -9 -1

MR_W08

8. Laboratory and other tests

(glucose, cholesterol, electrolytes)............................. 3 2 1 -9 -1

MR_W09

9. Treatment consistent with diagnoses ......................... 3 2 1 -9 -1

MR_W10

10. Health education about diagnoses ............................. 3 2 1 -9 -1

MR_W11

11. Health counseling about managing chronic disease.... 3 2 1 -9 -1

MR_W12

12. Numbers of visits to health care provider.................... 3 2 1 -9 -1

MR_W13

13. Evidence that client aware of her state of health 

and has a plan for changing or maintaining it.............. 3 2 1 -9 -1

MR_W14

14. Client shows improvement in state of health with 

diagnoses ................................................................ 3 2 1 -9 -1

2 0
MR—2006.00

Not to be used without the written permission of Karen Allen, Ph.D.

CHILDREN

Please document the actual numbers of the information being requested below. Record the child’s ID on top of each column. 

(If more than four children are treated, attach additional sheets.) 

1. If child born to mother while she is in treatment:

CHILD |__|__| CHILD |__|__| CHILD |__|__| CHILD |__|__|

Apgar score |__|__|

MR_APGAR

|__|__|

MR_APGAR

|__|__|

MR_APGAR

|__|__|

MR_APGAR

MR_HEAD_CIRCUMF

Head circumference

|__|__|.|__|

CM 1 IN 2

MR_UNIT_CIRCUMF

|__|__|.|__|

CM 1 IN 2

MR_UNIT_CIRCUMF

|__|__|.|__|

CM 1 IN 2

MR_UNIT_CIRCUMF

|__|__|.|__|

CM 1 IN 2

MR_UNIT_CIRCUMF

MR_BIRTH_LENGTH 

Length at birth

|__|__|.|__|

CM 1 IN 2

MR_UNIT_LENGTH

|__|__|.|__|

CM 1 IN 2

MR_UNIT_LENGTH

|__|__|.|__|

CM 1 IN 2

MR_UNIT_LENGTH

|__|__|.|__|

CM 1 IN 2

MR_UNIT_LENGTH

MR_BIRTH_WEIGHT

Birth weight

|__|__|.|__|

KG 1 LB 2

MR_UNIT_WEIGHT 

|__|__|.|__|

KG 1 LB 2

MR_UNIT_WEIGHT 

|__|__|.|__|

KG 1 LB 2

MR_UNIT_WEIGHT 

|__|__|.|__|

KG 1 LB 2

MR_UNIT_WEIGHT 

MR_GESTATION_AGE

Gestational age

|__|__|.|__|__|

in weeks

|__|__|.|__|__|

in weeks

|__|__|.|__|__|

in weeks

|__|__|.|__|__|

in weeks

MR_DRUG_SCREEN

Drug screen

|__| negative screen

|__| MR_COCAINE

|__| MR_METHADONE

|__| MR_OTH_OPIATES

|__| MR_MARIJUANA

|__| MR_METHAMPH 

|__| MR_ALCOHOL

|__| MR_NICOTINE

|__| MR_OTHER_POSITIVE

MR_POSITIVE_OTH

_____________

_____________

|__| negative screen

|__| MR_COCAINE

|__| MR_METHADONE

|__| MR_OTH_OPIATES

|__| MR_MARIJUANA

|__| MR_METHAMPH 

|__| MR_ALCOHOL

|__| MR_NICOTINE

|__| MR_OTHER_POSITIVE

MR_POSITIVE_OTH

_____________

_____________

|__| negative screen

|__| MR_COCAINE

|__| MR_METHADONE

|__| MR_OTH_OPIATES

|__| MR_MARIJUANA

|__| MR_METHAMPH 

|__| MR_ALCOHOL

|__| MR_NICOTINE

|__| MR_OTHER_POSITIVE

MR_POSITIVE_OTH

_____________

_____________

|__| negative screen

|__| MR_COCAINE

|__| MR_METHADONE

|__| MR_OTH_OPIATES

|__| MR_MARIJUANA

|__| MR_METHAMPH 

|__| MR_ALCOHOL

|__| MR_NICOTINE

|__| MR_OTHER_POSITIVE

MR_POSITIVE_OTH

_____________

_____________

2. This section is for any treated children. Please check the appropriate positive or negative (YES or NO) response. Record 

the child’s ID on top of each column. (If more than four children are treated, attach additional sheets.) 

CHILD |__|__| CHILD |__|__| CHILD |__|__| CHILD |__|__|

MR_C02

2. Immunizations up to date.........................................

Yes 1

No 0

Yes 1

No 0

Yes 1

No 0

Yes 1

No 0

MR_C03

3. Appropriate past medical history..............................

Yes 1

No 0

Yes 1

No 0

Yes 1

No 0

Yes 1

No 0

MR_C04

4. Completed history and physical ...............................

Yes 1

No 0

Yes 1

No 0

Yes 1

No 0

Yes 1

No 0

MR_C05

5. Allergies and adverse drug reactions .......................

Yes 1

No 0

Yes 1

No 0

Yes 1

No 0

Yes 1

No 0

MR_C06

6. Diagnoses of existing health concerns .....................

Yes 1

No 0

Yes 1

No 0

Yes 1

No 0

Yes 1

No 0

MR_C07

7. Laboratory and other tests.......................................

Yes 1

No 0

Yes 1

No 0

Yes 1

No 0

Yes 1

No 0

MR_C08

8. Treatment consistent with diagnoses .......................

Yes 1

No 0

Yes 1

No 0

Yes 1

No 0

Yes 1

No 0

MR_C09

9. Health education to mother about diagnoses............

Yes 1

No 0

Yes 1

No 0

Yes 1

No 0

Yes 1

No 0

MR_C10

10. Health counseling to mother about managing 

chronic illness .........................................................

Yes 1

No 0

Yes 1

No 0

Yes 1

No 0

Yes 1

No 0

MR_C11

11. Numbers of visits to health care provider..................

Yes 1

No 0

Yes 1

No 0

Yes 1

No 0

Yes 1

No 0

MR_C12

12. Evidence that mother/child aware of child’s state of 

health and has a plan for changing or maintaining it .

Yes 1

No 0

Yes 1

No 0

Yes 1

No 0

Yes 1

No 0

MR_C13

13.Child shows improvement in state of health with 

diagnoses.................................................................

Yes 1

No 0

Yes 1

No 0

Yes 1

No 0

Yes 1

No 0