Attachment I-Chart Review.pdf
PDF 206 KB Posted
- Attached to
- Breastfeeding Peer Counseling Services
- Solicitation number
- 25RFP-25-0904004-005
- Issued by
- Kingsbury County, South Dakota
About this file
This is a Breastfeeding Peer Counselor (BFPC) Chart Review form used by the South Dakota Department of Health WIC Program. The form is designed to evaluate peer counselors' performance across 8 key metrics, including timeliness of participant contact, adherence to contact schedules, documentation practices in SDWIC-IT system, communication with WIC staff, use of approved educational materials, scope of practice compliance, narrative documentation quality, and proper use of approved abbreviations. The form includes space for reviewing three separate cases, with Yes/No/NA options for each metric.
The document includes fields for basic client information such as Client ID Number, Client Name, WIC Category, Date of Certification, Infant Date of Birth, and Referral Date. The form features both the "Breastfeeding: A Work of Heart" logo and WIC program logo, indicating its official use in the peer counseling program. An "Additional Comments" section is provided at the bottom for reviewers to include supplementary observations or notes about the peer counselor's performance.
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Text version
Attachment I
Date Reviewer Peer Counselor
BFPC Chart Review Client ID Number
Client Name WIC Category
Date of Certification Infant Date of Birth
Referral Date
1. Peer Counselor contacted mother within established timeframe after referral.
Y N NA Y N NA Y N NA
2. Peer Counselor contacts mother according to the Schedule of Contacts.
3. Peer Counselor documents in SDWIC-IT within 1 week of contact.
4. Peer Counselor provides updates to WIC staff when participant has been referred.
5. Peer Counselor uses approved materials to provide education to participants.
6. Peer Counselor works within the established scope of practice and makes appropriate referral.
7. The narrative in SDWIC-IT provides a complete overview of contact with participant.
8. Were approved abbreviations used when documenting in SDWIC-IT.
Additional Comments:
File details come from the government source that posted it. Updated .