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PQCNC AIM clOUDi Prenatal Pilot Data

Page One

Patient Data Collection Form
This question requires a valid date format of MM/DD/YYYY.
calendar
3. Patient Race / Ethnicity *This question is required.
4. Payor *This question is required.
5. Was patient screened for substance use disorder (SUD) at a prenatal visit using a validated verbal or written screening tool? *This question is required.
6. Did patient screen positive for any substance use disorder using a validated verbal or written screening tool? *This question is required.
7. Did patient screen positive for SUD using any other means (NOT a validated verbal or written screening tool, e.g., urine drug screen, clinical observation, unvalidated verbal/written questions)?
  *This question is required.
Was patient referred for further substance use assessment and/or care? *This question is required.
When you submit the data will be recorded and the page will refresh allowing you to enter additional patients as needed.  When you have entered all patients you may simply exit the page.

Thank you for your commitment to the goal of verbally screening all pregnant women in North Carolina for substance use disorder with a validated screening tool!