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N.C. Department of Environment, Health, and Natural Resources Page 2 of 3 <br />Division of General Services <br />FY 1990 -1991 <br />CONTRACT ADDENDUM <br />Children and Ya th Section 91 -5454 -068 <br />Office, Section, or Branch Contract Number <br />Orange County Health Dept._ Children's Special Health. <br />Contractor Activity Services <br />CLINICAL SECT ION <br />Persons enrolled in a CSAS Clinic will be provided the following services as documented in <br />their medical records: <br />1. An estimated * % will receive a health history which includes the following <br />components: present problem, past medical history, developmental history, caregiving <br />history /status, nutrition history and family history. <br />2. An estimated * % will receive at each visit a review of systems which includes the <br />following components: head, skin, eyes, ears, mouth, throat /neck, respiratory, <br />cardiovascular, gastrointestinal, skeletal and neuromuscular. <br />3. An estimated * % will receive 3 out of 5 of the following other health - related <br />assessments: behaviors, medications, immunizations, nutrition /growth and equipment. <br />4. An estimated 100 % will receive at each visit a physical examination which includes: <br />pertinent examination and blood pressure. One -time scoliosis clinic, 100% of <br />patients will receive a pertinent examination but no blood pressures taken <br />5. An estimated 100 % will have a written diagnosis and plan of care. <br />6. An estimated N/_A % of eligible clients will receive diagnostic tests as indicated in <br />the plan of care. All patients referred for diagnostic tests. <br />7. An estimated N/A % of eligible clients will receive treatment services as indicated in <br />the plan of care. All patients referred for treatment. <br />8. An estimated 100 % will receive follow -up which includes the following components: <br />follow -up of missed appointments, sending summary clinic notes, monitoring treatment <br />and referral recommendations, completing and(submitting eligibility and /or <br />authorization forms.) All eligibility forms will be completed by 'physician <br />who renders treatment. Our one -time clinic will not complete forms. <br />9. An estimated 1002 will have documentation of communications to and from referral <br />sources and other providers. <br />10. An estimated _V/A% will have a signed release of information. <br />*N /A, one -time only scoliosis clinic <br />Review by <br />DEHNR 3300 (Revised 2/90) "li <br />General Services Division (Review 1/95) Initials Date <br />