POW'R Cessation Center - For Healthcare Providers

FOR HEALTHCARE PROVIDERS

MONTHLY ACTIVITY REPORT

BRIEF MONTHLY ACTIVITY REPORT

Monthly Activity Report is due by the 7th of the month, for the previous month's activities

* - required fields

Partner Name: *

Month reported: *

Date submitted: *

Screening

(Takes 1-3 minutes)

1. Number of patients screened for tobacco use this month? *

2. Number of patients indentified as tobacco users this month? *

3. Method of obtaining tobacco user information:
(select all that apply)

Chart Review (e.g., Med. Hx., intake forms)
Electronic medical record
Other electronic records
Patient Survey
Encounter forms (e.g., billing records)
Discharge plans
JCAHO core measures

Intervention

(Takes as little as 30 seconds)

1. Number of patients receiving brief interventions? *
(Include those given any information)

2. Intervention given
(select all that apply)

Quitline information
Brief intervention and/or counseling
Information on Medicaid benefits
FAX-to-Quit Referral forms
Other

Comments

Patients remaining abstinent from tobacco use for:
(If you are tracking them)

3 mos.
6 mo. or more
12 mo.

Barriers/problems:

Successes to share:

Did the program appear in any publications (internal or external)? If yes, please provide details: *

Were any government agencies/officials contacted about your tobacco program earlier this month?

YesNo

How many:

By phone
By letter
By email
By other

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POW'R To Be Tobacco Free Cessation Center (also known as POW'R Cessation Center) is one of 19 Cessation Centers in New York State which is funded through a grant by the New York State Department of Health Tobacco Control Program (NYS TCP). POW'R Cessation Centers main goal is to provide training and technical support to health care institutions and providers such as, clinics, home healthcare agencies, private practices, chemical dependency treatment centers, mental health agencies and dental offices in the design and implementation of systems to screen, identify and provide interventions and treatment for their tobacco-using patients based on the Public Health Service Clinical Practice Guidelines - "Treating Tobacco Use and Dependence" - 2000. POW'R Cessation Centers catchment area consists of Putnam, Orange, Westchester and Rockland Counties. We also assist hospitals and other healthcare facilities in all phases of becoming tobacco-free (including their entire campus). To further assist their patients and community to quit smoking, POW'R Cessation Center will train your staff to become smoking cessation facilitators.