Patient Navigation Data Entry – Form to Screen Crosswalk
Outreach Navigation Intake Form / MBCIS Patient Navigation Client Intake
Description
Form
MBCIS Screen
Date of 1st contact with client or date client verbally
acknowledges service provisions
Encounter #1 Date
First Encounter Date
The form taken of 1st encounter
If client is enrolled or enrolling in the Medicaid
Treatment Act (do not use Outreach Navigation
Intake Form, see Outreach Navigation MTA
Encounter Form)
Type of Encounter
Encounter Type
Client Identifier
Client Last Name
Client First Name
Client Middle Initial
Client Date of Birth
Client Age
Client Email
Street Address of residence
Apt number
City of residence
If unknown, use your agency’s county
State of residence
If unknown, use your agency’s zip code
Primary phone number
Type of phone number
Secondary phone number
Type of phone number
Number of people in household supported by
yearly income
Yearly income
N/A
Last Name
First
M.I.
Birth Date
N/A
Email
Street Address
Apt
City
County
State
Zip Code
Phone Number
(type of phone)
Phone Number
(type of phone)
BCCCNP MTA Client?
If Yes, Fill out Contact Information then go to MTA Client
Enrollment Tab
MBCIS – system generated once this screen is submitted
(saved)
Last Name
First Name
M.I.
Birth Date
Age – system generated, no data entry
Email Address (will appear in all caps)
Street
Apt
City
County
State
Zip Code
Phone 1
Type
Phone 2
Type
# of people in the household
Household Yearly Income
Client Verbal Acknowledgement for Services Obtained
Are you Hispanic or Latino?
Ethnicity
Race
Members
Income
Client Verbal Acknowledgement
Hispanic
Ethnicity
(list of racial categories)
N/A
Outreach Navigation Intake Form (bottom half of form: Client Assessment and Barriers Assessed) /
MBCIS Patient Navigation Client Assessment Screen
Description
Form
MBCIS Screen
Most recent screening information prior to
navigation services, if known
Previous Mammogram date (MM/DD/YYYY) if day is
unknown, use 01
Previous Mammogram Result - Normal, Abnormal,
Unknown
Previous Pap date (MM/DD/YYYY) if day is
unknown, use 01
Previous Pap Result - Normal, Abnormal, Unknown
Check type of screening test(s) that require
navigation services
Check type of breast diagnostic test(s) that require
navigation services
Check type of cervical diagnostic test(s) that require
navigation services
Check all that apply of barriers to obtaining service
that will be addressed by navigation
Check all that apply of barriers to obtaining service
that will be addressed by navigation
Check all that apply of barriers to obtaining service
that will be addressed by navigation
Check all that apply of barriers to obtaining service
that will be addressed by navigation
Date navigator will next contact client
Type of encounter for next contact
If client is eligible for caseload services check this
box and client information will transfer, navigation
services end
Document any additional information
Person in charge of client’s navigation services
Date navigator signed form
Screening Services Received
Screening Services Received (Prior to Navigation)
Mammogram Date
Mammogram Date
Result
Result
Pap Date
Result
Pap Date
Result
Screening Services Needed
Screening Services Needed
Breast Diagnostic Services Needed
Breast Diagnostic Services Needed
Cervical Diagnostic Services Needed
Cervical Diagnostic Services Needed
System Barriers
System Barriers
Financial Barriers
Financial Barriers
Psychosocial Barriers
Psychosocial Barriers
Communication Barriers
Next Encounter Date
Type of Encounter
Communication Barriers
Next Planned Encounter Date
Type of Encounter
Referred to BCCCNP
Comments
Navigator Name
Date Signed
Referred to BCCCNP Caseload Services
Additional Comments
Navigator Name
Date
Outreach Navigation Encounter Summary Form (Top Half)/
MBCIS Patient Navigation Follow-up Encounters Screen (Top Half)
Description
Form
MBCIS Screen
Date of any encounter beyond 1st encounter
Follow-up Encounter Date
Encounter Date
Form that the encounter took
Navigation Screening Services
Navigation Mammogram Date
Navigation Pap Date
Navigation Breast Diagnostic Services
Navigation diagnostic mammogram done
Navigation diagnostic mammogram date
Navigation ultrasound done
Navigation ultrasound date
Navigation MRI done
Navigation MRI date
Navigation breast consult done
Navigation breast consult date
Navigation biopsy done
Navigation biopsy date
Navigation other breast diagnostic done
Navigation other breast diagnostic date
Type of Encounter
Screening Services Completed
Mammogram Date
Pap Date
Breast Diagnostic Services Completed
Diagnostic Mammogram
Diagnostic Mammogram Date of Service
Ultrasound
Ultrasound Date of Service
MRI
MRI Date of Service
Breast Consult
Breast Consult Date of Service
Biopsy
Biopsy Date of Service
Other (Description)
Other Date of Service
Encounter Type
Screening Services Completed
Mammogram Date of Service
Pap Date of Service
Breast Diagnostic Services Completed
Diagnostic Mammogram
Diagnostic Mammogram Date of Service
Ultrasound
Ultrasound Date of Service
MRI
MRI Date of Service
Breast Consult
Breast Consult Date of Service
Biopsy
Biopsy Date of Service
Other (Description)
Other Date of Service
Outreach Navigation Encounter Summary Form /
MBCIS Patient Navigation Follow-up Encounters Screen
Description
Form
MBCIS Screen
Navigation Cervical Diagnostic Services
Navigation cervical consult done
Navigation cervical consult date
Navigation colposcopy done
Navigation colposcopy date
Navigation biopsy done
Navigation biopsy date
Navigation ECC done
Navigation ECC date
Navigation diagnostic LEEP / Cone done
Navigation diagnostic LEEP / Cone date
Navigation other cervical diagnostic done
Navigation other cervical diagnostic date
Type of cancer diagnosed
Status of Treatment
Date Treatment Started
Date referred to the BCCNS Navigation Consultant
Date referred to ACS services
Description of referral to other community services
Date client referred to other community services
[Is it necessary to contact client again? No] status
= Complete, Lost to Follow-up, Refused – fill out
completion date.
Cervical Diagnostic Services Completed
Cervical Consult
Cervical Consult Date of Service
Colposcopy
Colposcopy Date of Service
Biopsy
Biopsy Date of Service
ECC
ECC Date of Service
Diagnostic LEEP / Cone
Diagnostic LEEP / Cone Date of Service
Other (diagnostic test)
Other Date of Service
Cancer Diagnosis
Treatment Status
Treatment Start Date
Referrals BCCNS Navigation Consultant
Referrals ACS
Referrals Other (description)
Referrals Other Date
Cervical Diagnostic Services Completed
Cervical Consult
Cervical Consult Date of Service
Colposcopy
Colposcopy Date of Service
Biopsy
Biopsy Date of Service
ECC
ECC Date of Service
Diagnostic LEEP / Cone
Diagnostic LEEP / Cone Date of Service
Other (diagnostic test)
Other Date of Service
Cancer Diagnosis
Treatment Status
Treatment Date
Referrals BCCNS Date
Referrals ACS Date
Referrals Other (description)
Referrals Other Date
Outreach Navigation Status
Navigation Status
Navigation Completed Date
Next Encounter Date
Navigation Services/Referrals Provided to Resolve
Barriers (with comments)
Additional Comments
Navigator Name
Date Signed
Completion Date
Next Encounter Date
Navigation Services/Referrals Provided to Resolve Barriers
(with comments)
Additional Comments
Navigator Name
Date
[Is it necessary to contact client again? Yes]
Status = Follow-up needed – fill out next encounter
date
Only if status = Complete, lost to follow-up or
refused
Only if status = follow-up needed
Document methods used to resolve client barriers
to care
Document any additional information
Person in charge of client’s navigation services
Date navigator signed form
Description
Outreach Navigation MTA Encounter Form (Bottom Half)/
MBCIS Patient Navigation MAT Client Enrollment Screen
Form
MBCIS Screen
Client Enrollment Information
Type of first encounter (check one)
Top Half of Form
New Enrollment
Enter on Patient Navigation Client Intake Screen
New Enrollment
Type of first encounter (check one)
Date client signed MTA application
Type of second encounter (check one)
If follow-up encounter checked, enter date here
Type of second encounter (check one)
If MTA discontinued checked, enter date here
Document any additional information
Person in charge of client’s navigation services
Date navigator signed form
Re-Enrollment / Renewal
Date Application Signed
Follow-up Encounter (check box)
Follow-up Encounter Date
MTA Discontinued (check box)
MTA Discontinued Date
Comments
Navigator Name
Date Signed
Re-Enrollment / Renewal
MTA Signed Date
Follow-up Encounter (check box)
Follow-up Encounter Date
MTA Discontinued (check box)
MTA Discontinued Date
Additional Comments
Navigator Name
Date