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N.C. Department of Environment, Health, and Natural Resources <br />Division of General Services <br />CONTRACT ADDENDUM <br />Children and Youth S ctinn <br />Office, Section, or Branch <br />Orange County Orthopedic (Scoliosis) Clinic <br />Contractor <br />CLINICAL SECTION <br />Page 3 of 3 <br />FY 1991 -92 <br />5323 <br />92- 545*-060 <br />Contract Number <br />Children's S ecial Health <br />Activity Services <br />Persons enrolled in a CSHS Clinic will be provided the following services as documented in <br />their medical records: <br />1. An estimated * Z 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 S of the following other health - -related <br />assessments: behaviors, medications, immunizations, nutrition /growth and equipment. <br />4. An estimated 100 Z will receive at each visit a physical examination which includes: <br />pertinent examination and blood pressure. One -time per year scoliosis clinic, 1C0% of patients <br />will receive a pertinent examination but no blood pressure taken. <br />S. An estimated IQQ�Z will have a written diagnosis and plan of care. <br />6. An estimated NIA X 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 Z 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 physicians who renders <br />treatment. Our one -time per year clinic will not complete forms. <br />9. An estimated will have documentation of communications to and from referral <br />sources and other providers. <br />10. An estimated _WA Z will have a signed release of information. <br />*N /A, one time per year scoliosis clinic. <br />DEHNR 3300 (Revised 2/90) <br />General Services Division (Review 1/95) <br />Reviewed by <br />Initials <br /><1 4. -q1. <br />Date <br />